Last year saw the release of two large physician databases—Open Payments and the “Medicare Provider Utilization and Payment Data” files, which contain Medicare Part B fee-for-service payments, listed by physician. While the Sunshine Act was many years coming, the Medicare billing data caught many by surprise. Now, neither show any sign of slowing down. The Medicare data release took place in early April last year, but not without a fair share of controversy and misleading news reports. A recent article entitled “When Transparency Isn’t Transparent” written by associate clinical professor of surgery at Mount Sinai Hospital, Joel Zinberg, further articulates some potential problems with the data release. This “new policy will accomplish little beyond confusing patients and embarrassing physicians,” he argues.
Last year, Jonathan Blum, then the principal deputy administrator at CMS, announced that 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. CMS released their data in a dozen giant, difficult-to-read spreadsheets (even by Open Payments standards). However, several national publications created user-friendly databases for the public to explore.
The New York Times and Washington Post seemingly had their “Find a Doctor” tools ready the minute CMS released the payment data. The Wall Street Journal’s database allows users to search by doctor name, company, specialty, city, or state. Soon after the national news outlets covered the release of Medicare payments, regional newspapers began to seize the opportunity as well. Countless articles across the country ran variations of “Find Out How Much Your Doctor Receives from Medicare.”
Proponents of transparency argue that the public release of Medicare data could put pressure on healthcare providers to rein in overtreatment and the use of unnecessarily expensive procedures. The data could also potentially steer patients to the most “experienced” doctors, if judged purely on the number of Medicare-paid procedures. However, without more context, the data is both unclear and unduly prejudicial to many physicians—especially those who practice in high-cost, specialized areas or who simply see a lot of patients. Zinberg’s article fleshes this potential prejudice out in his article.
“The problem is that patients cannot intelligently interpret the CMS data,” Zinberg argues. “If the records show, for example, that a doctor has received what seem like high payments for a particular procedure—and for performing that procedure an unusual number of times—is the doctor an expert, or a crook?” He states that “[h]ealth researchers have long maintained that high-volume providers have better outcomes. Perhaps the doctor is especially proficient, and her expertise attracts large numbers of patients who need the procedure? The CMS records won’t help patients assess the quality of the services provided or compare one doctor with another.”
“The payment records could also mislead patients because they don’t indicate whether a payment was made to a single provider or to multiple providers out of a single office, using one provider’s Unique Physician Identification Number for billing purposes,” states Zinberg. “A pathologist in Minnesota collected $11 million from Medicare in 2012. It wasn’t fraud; he was chairman of the Mayo Clinic’s Department of Laboratory Medicine and Pathology, one of the busiest in the country, and the entire lab billed under his name and Medicare number.”
Zinberg also honed in on the fact that reimbursements do not necessarily equal profit in doctors’ pockets. “When a hematologist or oncologist administers chemotherapy, the drug’s cost to the doctor dwarfs what he can collect. The same is true for ophthalmologists who administer macular-degeneration treatments,” he notes. “Current Medicare rules allow physicians to collect the average sale price of the drug plus 6 percent. The actual margin, however, may be less, when overhead costs are factored in. Small practices that purchase drugs in small amounts at higher than ‘average’ costs may actually lose money.”
Furthermore, Zinberg was critical of the utility of this data. “Unfortunately, the payment records provide no insight into the severity or complexity of diseases treated by doctors, so they cannot be useful for comparing costs and utilization among providers or different regions,” he states. Although he believes “[o]utliers in total billings or total procedures performed warrant further investigation,” he argues that this information is “already available to law enforcement and regulatory authorities. In fact, many physicians with unusual billing patterns in the 2012 record release had already been disciplined by state medical boards and/or law enforcement.”
Zinberg concluded:
One is left with the suspicion that the primary purpose of the record release is to shame doctors whom policymakers believe routinely exploit the current fee-for-service payment system for personal gain. True, some physicians are guilty as charged; as in any profession, some bad apples exist. But most physicians take their professional duties seriously. They make a good faith effort to perform services for the best interests of their patients and not for personal gain. They don’t deserve to be pilloried based on misleading information. Until Medicare payment records can be made useful and readily intelligible, CMS should suspend their release. If CMS insists on going ahead, it should at least help people understand what they’re looking at.
View our coverage of the Medicare payment release last year, where we raised some similar points.