Physician Payments Sunshine Act: Physician Review Period Marred By Technical Difficulties, Missing Payments, and Uncertainty
On Tuesday, we walked through the problematic Open Payments roll-out from a manufacturer perspective. Today, we will outline the arduous path that physicians and teaching hospitals have had to tread in order to simply review their payment data—only to find missing payments or error screens. We hope by walking through the process, we can alert physicians to potential problem areas and bring attention to CMS as to lingering issues and our concerns with the system.
We talked with Steven Ladd, the President of Primacea, who has navigated the Open Payments system on behalf of many physicians. He offered his perspective on the process, and discussed his clients’ fears about the accuracy of Open Payments data, as well as the media response once these payments are publicly posted.
According to Ladd, physicians mainly fear a repeat of the Medicare data release from earlier this year. News coverage was quick to criticize doctors who were paired up with large dollar sums. However, most failed to note that Medicare payments do not, in fact, equal income. Payments often cover large staff salaries, expensive drugs, and medical equipment. Furthermore, too much of the data was simply incorrect.
The upcoming Open Payments release portends similarly misplaced stigma. Physicians are unable to provide proper context to, for example, research payments where the entire cost of a research project is allotted to one principal investigator. This could be a multi-million dollar payment spread out to cover a wide variety of essential costs. While we are skeptical that the media will cover these realities, the Open Payments system in theory allows physicians to check the accuracy of what companies have reported about them. Physicians are anxious to review this data to make sure that it is correct, but they have faced many obstacles along the way.
Registration
In order to view payments, physicians must go through EIDM registration, Open Payments registration, and then complete an Open Payments profile. To lead users through this process, the Centers for Medicare and Medicaid Services (CMS) released a 359-page guide for Open Payments. Many physicians were turned away simply by the amount of time they would need to spend away from their patients in order to understand the system. Physicians who braved the process had to wait in between registering for EIDM and Open Payments—sometimes for several hours.
The Open Payments system requires physicians to answer certain questions about their financial history in order to log-in. At the recent CBI Aggregate Spend Conference in Washington, DC, several speakers noted that physicians are often alarmed that CMS would be checking their credit before allowing them access to review their payments. Indeed, no one wants to see a government agency come up on their credit inquiry list.
Beyond the intrusive nature of the process, many questions simply require doctors to spend an inordinate amount of time researching the answers. Because the process must be completed in one sitting, and has no auto-save feature, doctors often have to re-submit their answers repeatedly. Furthermore, Open Payments initially required doctors to use Internet Explorer–a browser used by less than 50% of Americans.
Thus, when all is said and done, in a “perfect” registration process, doctors have to work through an arduous procedure, wait around for up to several hours in between steps, continuously log-out and sign back in, and then repeat the procedure if they need additional time, or forgot their password:
Open Payments Delays
On top of an already complicated registration process, the Open Payments dispute resolution experience has been plagued with errors and delays. Initially, physicians who had received no payments, experienced an “error” message when they attempted to log-in. Without any guidance from CMS about this, physicians would have no idea if the system was simply malfunctioning, or if manufacturers submitted incorrect information.
The images at the top of the article and below show screenshots from some of the problems that Primacea encountered when working with its clients.
Furthermore, CMS has officially taken the system offline for extended periods of time. Open Payments was down for 12 days in early August, not long after the review period first launched. One of the problems that many physicians and representatives faced was that they had no idea what caused the problem, if it was just their own system, or when the issue would be fixed. CMS waited almost a full week before making an announcement:
CMS Email, dated August 7, 2014; 3:58 PM:
“The Open Payments system has been taken offline temporarily to investigate a reported issue, so physicians, teaching hospitals and authorized representatives may not register and review data at this time…”
We are concerned that these continued delays in the system resulted in less and less physicians waiting around to review their data within the system. The process has proven to be challenging enough without the delays. Unfortunately, most recently, CMS announced additional outages where physicians would be unable to use the systems, on August 30 and September 5.
CMS is now running an advertisement on google. We appreciate the outreach to physicians, but CMS ironically describes the process as taking “only a few simple steps.”
Missing Data
After the 12-day shutdown, physicians found that many of their payments, which were often correct values, had been removed. We later determined that CMS removed many items due to matching problems within the system.
Additionally, last week ProPublica posted that certain research payments were also going to be removed from the public database. “Doctors apparently have not been given a chance to verify and dispute payments attributed to them, as required by law,” states the article. “Officials at CMS have not publicly disclosed anything about this latest batch of withheld data and did not answer questions from ProPublica about how many records are involved.”
Without an official announcement from CMS, however, this has been incredibly frustrating for physicians looking to validate what will potentially be reported on them on September 30th.
Ladd notes that in his role at Primacea, he has seen that a high percentage of the remaining payments are small “food and beverage” items. However, he states that physicians are worried about not being able to review and dispute research payments made to teaching hospitals.
The Open Payments system splits access to the database up between physicians and teaching hospitals. Physicians only have access to the physician database, and may only view payments made specifically to them. In many cases, however, a teaching hospital will receive large research payments and the reporting entity will put that dollar amount in the name of the physician principal investigator for Open Payments purposes. Often these payments can be in the thousands or millions of dollars.
A few physicians were accidentally given access to teaching hospital databases. The CMS Help Desk advised at least one physician to select the role of “Authorized Official” to view the teaching hospital data. This led to a situation in which a hospital physician would essentially be “in charge of all of a teaching hospital’s Open Payments data,” says Ladd.
The problem remains, however, that most physicians cannot review payments made to teaching hospitals without contacting each teaching hospital that may have payments associated with them. This is far from an ideal process.
Biggest Concerns: Uncertainty and Lack of Context
- What will be reported?
No physician wants to see his or her name in the newspaper as receiving a huge sum of money from industry when that information is either untrue or misleading. A Massachusetts doctor we spoke with typed his name into the system to find every one of his payments was entered into the wrong Open Payments category–research and travel went in consulting, other payments went in travel, etc. This issue comes to a head when doctors have agreed not to accept consulting fees, and would have to explain why they have been reported. Thus, it is important for physicians to review and dispute the incorrect information they find next to their name.
However, because physicians do not have the option to register and view teaching hospital data, many physicians will be unable to view all of their allotted payments. Teaching hospital research payments in the thousands or millions of dollars may be attached to a single physician’s name who never had the opportunity to review the data for accuracy. The “review and dispute” process, in other words, will typically only reveal payments made by companies directly to the physician.
Most problematic, though, is the fact that CMS has not specifically stated which data they will withhold from the September 30 release date. Uncertainty surrounding what will actually show up in the public database is causing concern in the physician community, notes Ladd.
- Will the media provide context?
In addition, physicians are rightfully worried about how much context the media and other news outlets will provide next to their list of “Physicians Who Received the Most Industry Money.” We didn’t see much context at all in the early articles surrounding the Medicare payments release, and this is very troubling.
The central issue boils down to this: News articles will demonize the very largest industry payments to physicians, which more often than not will be for important research initiatives. The work these doctors do is directly tied to advancing patient health, and they receive a very small fraction of the dollar amount that will show up in the system.
The press could thus miss the payments that the Sunshine Act intended to expose—fraudulent activities and kickback arrangements.
Ladd sums this up eloquently by noting that without proper context, the Sunshine Act “could mistakenly shine a bright light on the good, while letting the bad slip through the cracks.”
Steven Ladd is Co-founder and President of Primacea, Inc., which provides tools to physicians and leading hospitals to facilitate transparency in innovation and manage compliance obligations. For more information, please follow @Primacea on Twitter or visit www.primacea.com.