A tiny fraction of the 880,000
doctors and other health care providers who take Medicare accounted for nearly a
quarter of the roughly $77 billion paid out to them under the federal program,
receiving millions of dollars each in some cases in a single year, according to
the most detailed data ever released in Medicare’s nearly 50-year history.
In 2012, 100 doctors received a
total of $610 million, ranging from a Florida ophthalmologist who was paid $21
million by Medicare to dozens of doctors, eye and cancer specialists chief among
them, who received more than $4 million each that year. While more money by far
is spent for routine office visits than any other single expenditure, one of the
most heavily reimbursed procedures — costing a total of $1 billion for 143,000
patients — is for a single treatment for an eye disorder common in the
elderly.
The Medicare data — all for 2012
and the subject of an intense legal battle — provides an unprecedented look at
the practice of medicine across the country, shedding fresh light on the
treatment decisions physicians and other practitioners make every day. It will
also provide consumers with an ability to compare doctors and treatments in a
way they have never had until now.
Fraud investigators, health
insurance plans, researchers and others will spend weeks poring over the
information about how many tests were ordered and procedures performed for every
provider who received Medicare payments under Part B, which excludes payments to
hospitals and other institutions. The Centers for Medicare and Medicaid Services
is making the data publicly available on Wednesday. While total Medicare
spending — including hospitals, doctors and drugs — is approaching $600 billion
a year, payments to individual doctors have long been shrouded in secrecy. For
decades, the American Medical Association, the powerful doctors’ group, and
others have blocked the release of the information, citing privacy concerns and
the potential for misuse of the information. But a federal judge ruled last year
that the information could be made public.
Medicare paid $12 billion for 214
million office and outpatient visits, most of them described as between 15 and
25 minutes long. The practitioners — usually doctors, but sometimes nurse
practitioners, were paid an average of $57 a visit.
Much of Medicare spending is
concentrated among a small fraction of doctors. About 2 percent of doctors
account for about $15 billion in Medicare payments, roughly a quarter of the
total, according an analysis of the data by The New York Times. These figures
exclude commercial entities like clinical laboratories and ambulance services,
which account for $13.5 billion of the $77 billion total. Only a quarter of the
doctors are responsible for three-quarters of the spending. Medicare provided
The New York Times with an advance look at the information but requested that
individual doctors not be contacted until the data was made public. A database,
searchable by doctors’ names, is available at nytimes.com.
“This is actually the most useful
data set that Medicare has ever released,” said Dr. Bob Kocher, who served in
the Obama administration and is now a partner at Venrock, a venture capital
firm. People will be able to see just how many elbow surgeries a given
orthopedic surgeon has performed on Medicare patients, he said, and they will be
able to better judge a doctor’s style of practice, for example, whether a CT
scan is performed on every patient or only rarely. “You’re going to see
variation,” he said.
The American Medical Association,
which chose not to try to block the release of the information, questioned the
usefulness of these payments to assess doctors.
“We know there are going to be
limitations,” said Dr. Ardis Dee Hoven, the president of the association. “It’s
raw claims data. This gives us no window into quality or anything of that
nature.” While patients may know who performs a high number of procedures, like
hip replacements, for example, they will not be able to tell anything about
whether the patients needed the surgery or whether they benefited from the
surgery.
What’s more, Dr. Hoven cautioned,
doctors were not able to review the data, and some of the information being made
public could be wrong.
But the release of the information
is likely to increase attention to particularly controversial areas of spending.
About 3,300 ophthalmologists, for example, were paid a total of $3.3 billion
from Medicare, according to the Times analysis. Much of the spending was the
result of an expensive and frequent treatment for a kind of age-related macular
degeneration, the leading cause of severe vision loss in the elderly, and the
cost of the drug is factored into the payments doctors receive. Ranibizumab,
known by the brand name Lucentis, is injected into the eye as often as once a
month. A cancer drug that is used as an alternative can cost much less. Other
specialists also account for large portions of Medicare spending. Fewer than
1,000 radiation oncologists, for example, received payments totaling $1.1
billion.
Regulators and others are also
likely to seize on some of this information to find those doctors who perform an
unusually high volume of services, raising the question of whether every test or
procedure, like the placement of a cardiac stent, was medically necessary.
“There’s a lot of potential for
whistle-blowers and justified worry for fraudsters,” said Steven F. Grover, a
lawyer who represents whistle-blowers who sue doctors and hospitals who they
claim have committed fraud against the Medicare program. “There’s going to be a
lot of litigation over this,” he said.
The Office of Inspector General
for the Department of Health and Human Services, which serves as a federal
watchdog on fraud and abuse for the agency, released a report in December
recommending greater scrutiny of those physicians who were Medicare’s highest
billers. The report recommended that Medicare establish a threshold to look more
closely at the high billers. Regulators have also said they are scrutinizing the
use of high-paying codes in places including the emergency room.
Health insurance companies, which
must now rely on only the claims they handle to look at doctors, are also likely
to find the information valuable, according to Paul B. Ginsburg, a health
economist and professor at the University of Southern California. Marrying the
Medicare information to their own information, “all of a sudden they have a lot
more to work with,” he said, in trying to better determine how an individual
doctor treats patients — ordering lots of tests, for example, or being slow to
operate. “This is going to be a very important change,” he said.
Experts say the data must be used
with caution. An individual doctor, for example, may seem to have a high volume
of services because that doctor oversees medical residents or physician
assistants but bills for those services. Medicare patients may be only a
fraction of the patients a doctor sees.
Despite its limitations, however,
policy experts largely praised the release of the information, arguing that this
was an important step to understanding how doctors practice medicine in this
country.
“Any time Medicare releases a lot
of data, it changes the conversation in America about transparency, about cost
and quality,” said François de Brantes, the executive director of the Health
Care Incentives Improvement Institute. “It’s more a signal from Medicare to
market,” he said.