Q. What is the Medicare Physician Data Release, and where can it be found?
A. The Centers for Medicare & Medicaid Services released data on more than 880,000 health-care professionals on April 9, 2014. The data was previously inaccessible to the public. The data includes the number, type of services and associated Medicare payments for services delivered to Medicare Part B beneficiaries in 2012 for each of these providers. The cumulative total of payments in this data release is $77 billion. It is expected that the 2013 data will be released in 2015.
The data resides on the CMS website, and can be found by searching on “Medicare Physician Data Release.”
Q. Did ophthalmology realize significant payments in the data release?
A. Yes. Of the top 25 highest-paid providers in the release, 12 are ophthalmologists, and the number one physician on the list is an ophthalmologist.
Q. Is this the first time this data was released?
A. No. In March 1977, the Department of Health and Human Services made public the names of physicians or physician groups whose billing reached $100,000 or more of Medicare payments in 1975. In November 1977, the Secretary of HHS directed its carriers to publish another more detailed list, identifying all physicians and providers who received Medicare reimbursements in 1977. Prior to the anticipated release date of April 30, 1978, the Florida Medical Association and six individual physicians filed suit alleging that further release of such information would violate the Freedom of Information Act, the Privacy Act, the Trade Secrets Act and the United States Constitution. After the filing of various other legal motions, on October 22, 1979, the court issued a “Final Declaratory Judgment and Permanent Injunction” precluding the release of information.
Q. If an injunction existed to preclude the release of information, how did the 2014 release occur?
A. On January 25, 2011, Dow Jones Inc., publisher of The Wall Street Journal, filed a Motion to Intervene in this case. Its goal was to remove the 1979 FMA Injunction. On May 31, 2013, the injunction was lifted, opening the door for the April 9, 2014 release.
Q. What is the purpose of releasing this data?
A. President Obama stated early on in his presidency that he wanted a more open, involved and cooperative government. He set in motion an open-data policy in all federal departments. The catchword associated with this initiative has been “transparency.” CMS believes that this term captures the purpose of the data release. The attitude of CMS is that by making this payment information available, beneficiaries and consumers can better understand the delivery of care through the Medicare program and ultimately improve the system.
Q. Are there limitations to how the data is presented?
A. Yes. The data, although very dense and detailed, has limitations, particularly for those uninitiated to the Medicare program and how physicians are paid. Some of the limitations are:
1. The data is specific to Medicare Part B beneficiaries only. No data for patients with Medicare Advantage (Part C) plans is included. This currently comprises about 30 percent of Medicare beneficiaries. As a result, the information does not represent the full complement of patients a physician serves and is thus not a full disclosure of aggregate physician reimbursement.
2. CMS reported paid claims, which always contain some errors. In response to physician criticism of the accuracy of the data, CMS suggested physicians report their concerns, including the possibility that payments were made to the wrong provider.
3. Physician payment rates differ depending on geography. For example, in 2012, cataract surgery (CPT 66984) was allowed at $805.59 in metropolitan Boston, but in Alabama it was allowed at only $688.93.
4. No distinction regarding the quality of care or the medical necessity of the services delivered exists in the data set. ICD-9 codes are omitted from the report.
5. Modifiers skew the data but are not reported. For example, 66984-RT (cataract surgery), 66984-54 (intraoperative care only), and 66984-55 (postop care only) are lumped together in a single line within the report, although the values of these services are substantially different.
6. Payment for injected drugs is included in the report although these drugs are a supply and also represent a sizeable cost to the physician. For ophthalmologists, high-cost anti-VEGF medications, such as Lucentis, tend to dramatically increase total reimbursement.
Q. Is there a use of this data for the individual provider(s)?
A. If handled and presented appropriately, it can be useful in marketing and advertising efforts. It can assist in identifying referral sources and similar providers.
Q. How did the media react to the information in the data release?
A. Immediately following the release, the news media began publishing some of the information with sensational headlines, including “Taxpayers Face Big Medicare Tab for Unusual Doctor Billings,” “Medicare Millionaires Emerge in Data on Doctor Payments” and “How Much Does Your Doctor Really Make?” Some newspapers published the names of local physicians and their 2012 Medicare payments on the front page. Most articles cited ophthalmologists as receiving some of the largest amounts.
Q. How should ophthalmologists respond if approached by the media about this data and future data releases?
A. Various medical societies, including the American Academy of Ophthalmology and the American Society of Cataract and Refractive Surgery, published their analysis of the data and suggested how physicians should respond if approached by the media or their patients:
• Act positive and put a positive spin on the data release;
• Demonstrate expertise and provide up-to-date information about these procedures;
• Describe how patient’s lives are improved, sometimes dramatically;
• Describe how society benefits from patients with better vision (that you made possible);
• Make a point that practice makes perfect, so busier surgeons tend to be better surgeons;
• Don’t act defensively or play the blame game; and
• Don’t deny the data, but do point out some of the limitations.
Q. Who else might be interested in this data?
A. One concern about the use of the data is that fraud investigators and potential whistleblowers will be interested and interpret the data inaccurately, creating unnecessary lawsuits. In addition, other payers, accountable care organizations, independent physician associations, investors and competitors may be interested. REVIEW
Ms. McCune is vice president of the Corcoran Consulting Group. Contact her at DMcCune@corcoranccg.com.
