CMS Publicly Releases Medicare Part B Payment Data

On Wednesday, CMS publicly released Medicare physician payment data for the first time since 1979, showing how the program paid out $77 billion to more than 880,000 health care providers in 2012, the Los Angeles Times reports (Terhune et al., Los Angeles Times, 4/8). Thirty-eight of the top-paid doctors practice in California, according to the report (Alonso-Zaldivar/Tumgoren, AP/Sacramento Bee, 4/9).

About the Data

The data include information on payments made under Medicare Part B in 2012 to all participating providers. Specifically, the data include:

• Physicians' names and addresses;
• Summaries of the services provided; and
• The amount providers were paid for the services.

The data do not include any patient information. Further, CMS will not release any information on providers with fewer than 11 patients who are Medicare beneficiaries (California Healthline, 4/3).

The data show that Medicare paid $12 billion for about 214 million office and outpatient visits in 2012 (Abelson/Cohen, New York Times, 4/9).

Small Portion of Docs Receive Large Sums

Most providers received relatively modest Medicare payouts, the Los Angeles Times reports. However, about 2% of physicians and other individual providers accounted for almost one-quarter of the $77 billion total (Los Angeles Times, 4/8).

Overall, about one-quarter of providers participating in Medicare receive about three-quarters of the total payments, according to the data. Specialists tended to receive higher reimbursements. For example, about 3,300 ophthalmologists were paid about $3.3 billion under the program, as reimbursement for a frequent but expensive treatment for age-related macular degeneration. Meanwhile, fewer than 1,000 radiation oncologists accounted for reimbursement payments of more than $1.1 billion.

Some individual physicians received particularly high sums. For example, 100 physicians in 2012 accounted for $610 million in reimbursements, including an ophthalmologist who was paid $21 million under the program and several dozen eye and cancer specialists who each received more than $4 million.

'Unprecedented' Level of Transparency

According to the New York Times, the data "provides an unprecedented look" at the U.S. health care system and shines "fresh light" on day-to-day treatment decisions. Further, the information will give consumers the ability to compare providers and treatments in a manner never before available, according to the New York Times (New York Times, 4/9).

Marty Makary, a cancer surgeon at Johns Hopkins School of Medicine and the author of a book that argues for making data on doctors and hospitals more publicly available, said, "While the data are not perfect, this is a major milestone in health care transparency" (Begley/Pell, Reuters, 4/9).

Officials, Advocates Warn Against Misinterpreting Data

According to the Los Angeles Times, many stakeholders cautioned the public against misinterpreting the data.

For example, federal officials said that the high payouts do not necessarily indicate instances of fraud or over-billing, as payments could have been boosted by physicians treating particularly ill populations or because they have tailored their practices to treat Medicare beneficiaries (Los Angeles Times, 4/8). In addition, other experts said that an individual doctor might seem to have been paid for an unusually high number of services because he or she oversees medical residents or physician assistants, while billing for the services him or herself.

Ardis Dee Hoven, president of the American Medical Association, said, "We know there are going to be limitations" because it is "raw claims data." Hoven added, "This gives us no window into quality or anything of that nature," such as whether patients benefitted from treatments or if the surgeries and medical services were necessary. In addition, Hoven said that physicians should have been able to review the data, and that the information could contain flaws.

Information Will Be Used To Identify Waste, Fraud

Regulators, insurers and other industry stakeholders are likely to use the information to locate potential sources of waste and fraud in the system, according to the New York Times.

For example, Paul Ginsburg, a health economist and professor at the University of Southern California, noted that insurers using the Medicare data in addition to their own information will "have a lot more to work with" in determining how physicians treat their patients, such as whether they order too many tests or if they are slow to operate (New York Times, 4/9).

The data could offer a "roadmap" for where fraud and waste are occurring in the U.S. health system, Reuters reports. John Santa, a doctor and medical director for Consumer Reports, said, "If you see that a doctor is doing a procedure hundreds or thousands of times that should be done only on a small number of patients, you wonder" (Reuters, 4/9).