This week the Centers for Medicare and Medicaid Services (CMS) released raw data on how individual medical providers treat America’s seniors. This is a historical publication into how Medicare expenditures are distributed because access has been denied since 1979, when a Florida court issued a permanent injunction barring the government form releasing information about Medicare Part B payments to individual physicians in any manner that would allow the doctor to be identified. However, in 2011, the parent company of The Wall Street Journal successfully sued to overturn the injunction.
The data provided by CMS on Wednesday shed light on how 888,000 practitioners received payment for performing over 6,000 different procedures in fiscal year 2012. The data shows the providers' names, addresses, specialties, number of Medicare beneficiaries and number of services provided for every Medicare provider. In addition, each provider lists a billing rate per service, and then what Medicare actually paid. Various news outlets even allow curious users to enter in their physician’s name to find out information on their physician’s practice.
The results have been quite interesting. Reimbursements to doctors who provide Medicare services ranged from nearly $21 million to a single Florida ophthalmologist to the $27,000 for the average anesthesiologist. The data reveals wide variances in reimbursements, procedure costs and what services are provided to Medicare beneficiaries. Each and every provider has a set amount for a procedure, but he or she negotiates with an insurer, a private payer or the government to come up with a final cost. Medicare also bases its payment on a complicated formula that has absolutely nothing to do with what a provider bills.
Health-care economists say the data—despite several limitations—could help pinpoint doctors who over-treat patients, performing far more surgeries, procedures and other services than their peers. Fraud investigators already use similar data to identify doctors and specialties prone to waste and abuse. And more hospitals and health systems are using such data to compare doctors to encourage high-cost physicians to limit certain expensive services.
The data don't show details of patients' diagnoses, dates of procedures or other information that might help determine whether the care provided might or mightn't be necessary. Some doctors who perform lots of costly surgeries are national experts with narrow specialties. The American Medical Association notes that doctors couldn't review their billing totals before the U.S. released the data.
Moreover, only procedures that providers performed on more than 10 Medicare patients are counted, and CMS didn't release data on durable medical equipment. As a result, more than $22 billion out of $99 billion in 2012 Medicare spending on physician and provider services are missing from the data.
Spending on the Medicare program, which covers about 60 million elderly and disabled Americans, is expected to exceed $600 billion this year. There is broad agreement that fraud is rampant in both Medicare and Medicaid, the government health program for the poor, but estimates of the scope vary from $20 billion annually to $100 billion.
