Wednesday, September 03, 2014

Here's one view about Medicare billing transparency

While others have dispassionately made the point that there are unexplained variations in Medicare physician billing data that warrant careful consideration when using such data, one doctor thinks CMS has devious motives.  He says, "I believe that the release of these data by CMS was an attempt by policymakers to sway public opinion against physicians and lessen our political power in Washington." I summarize without comment, but I welcome your reactions.

David F. Penson, Department of Urologic Surgery, Vanderbilt Center for Surgical Quality and Outcomes Research, at Vanderbilt University Medical Center, published an article in the journal Urology, called "The Hidden Agenda in the Release of the Medicare Physician Reimbursement Data."  (Volume 84, Issue 3, Pages 501–502, September 2014.) Excerpts: 

On April 9, the Centers for Medicare and Medicaid Services (CMS) released data on Medicare reimbursements made to individual health-care providers in 2012. The government claims that this was done for the sake of transparency, to reduce fraud, and to encourage Americans to seek high-value healthcare. Call me paranoid, but I cannot help but wonder if there might be something more here.

If the goal of releasing these data is truly to increase transparency, reduce waste, and help market forces to improve the efficiency of health-care delivery in this country, the data have to be complete and accurate. This, however, may not be the case. For example, if Medicare services provided by a number of health-care professionals are billed under a single provider, which may be the case in certain programs and/or clinics, that individual will have these services wrongly attributed to them. In cases where the individual physician did actually provide the services, the data do not account for differences in case mix, as some providers really do see sicker patients than others. To this end, these physicians may get reimbursed to a greater degree, but these larger amounts may be entirely appropriate. Finally, there are going to be cases where the data are just simply wrong. 

It is worth noting that, in reviewing the “frequently asked questions” page on CMS's website, I was unable to find a link for physicians to question the accuracy of their data. However, I do not think CMS is concerned with my opinions on these data.

So, if CMS is not interested in the physician's concerns about the accuracy or validity of the data, what are they concerned with? Certainly, I believe that there is likely some truth to their statements around increasing transparency, eliminating waste and fraud, and trying to empower patients to select high-value healthcare. That being said, I believe there is a hidden agenda here. The Medicare physician reimbursement data were released just weeks after the passage of yet another temporary legislative patch for the sustained growth rate (SGR) cuts to providers. The SGR cuts are always the focus of physician lobbying efforts and, ultimately, politicians are well aware of the negative fallout that would occur if these cuts actually went through. By showing the public just how much Medicare currently pays physicians, it may lessen the political fallout of letting the SGR cuts go through.

In addition, immediately after the release of the data, the media ran a number of stories showing how some of the highest Medicare billers were also some of the largest political donors in the United States. Was either of these events a coincidence? I do not know, but I doubt it. I believe that the release of these data by CMS was an attempt by policymakers to sway public opinion against physicians and lessen our political power in Washington. Ultimately, the clinicians must be the ones at the table informing the discussion on the effectiveness of treatments and defending our patients' right to access to these therapies. If policymakers can turn the public against physicians and neutralize the voice of organized medicine on Capital Hill, it will be easier for them make unilateral changes to the Medicare program in the United States that may lessen costs but may also end up hurting patients.

I suppose the good news is that the modern news cycle seems to get shorter and shorter and the media has already moved on from this story. That being said, the government will release data on physician payments from pharmaceutical and device companies this fall. I am certain physicians again will be the focus of negative publicity when this occurs. Ironically, Congress will be considering another SGR fix at precisely the same time. Coincidence? I think not.


Barry Carol said...

I think the Dr. Penson is a bit cynical. I think issues like multiple providers in a clinic billing under one provider number and ophthalmologists prescribing Lucentis for macular degeneration at $2,000 per dose on which they make only a small profit margin among other issues can skew the data. It shouldn’t be all that hard to create a tool for doctors to either correct or amplify the data so people using it have a better understanding and appreciation of the doctors’ perspective. Given the massive technology failures associated with the rollout of, the problem here is more likely attributable to bureaucratic rigidity and incompetence.

At the same time, the consensus is that there is plenty of fraud in both the Medicare and Medicaid programs and the release of this data is, on balance, helpful in my view. As I understand it, fraud is especially prevalent in areas like post-acute care including physical therapy and home healthcare. We need to try to shed as much light on this as possible.

nonlocal MD said...

I am always amused by people who impute lack-of-coincidence or conspiracy motives to our federal government. (And they are not always Republicans.) If they have ever worked for it or closely with it, they would realize that, other than the NSA and such agencies, the government simply is far too inefficient for such theories to hold water. The left hand can hardly even see the right hand, much less coordinate with it.

Joanne Roberts, MD, MHA said...

I ask, why shouldn't Medicare make these payments public knowledge? The taxpayers are funding those payments. Conspiracy or not (and I would agree that Medicare is probably just about as efficient as the entire healthcare system in executing on conspiracies), the public has a right to know how its dollars are spent, whether on doctor payments, executive salaries (and I am a doctor executive), and other sectors of the system.
-- Joanne Roberts, Everett WA

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John said...

I tend to agree with him. The trend is to have physician services become a commodity in order to drive reimbursement down. What better way to suggest that there is room for price control by revealing individual physician reimbursements, regardless of accuracy, in order to set the perception. Another example is the dilution of the role of a general surgeon. More and more positions are "procedure" focused as hospitals only want the technical component provided by the surgeon.