The Centers for Medicare and Medicaid Services (CMS) just released the mother lode of data on individual payments and bills submitted and collected by physicians participating in the Medicare program.
CMS said this unprecedented release of the information is to help consumers make better choices. Not everyone agrees.
The Data Set
The data, which is called the Carrier Standard Analytical File, was released to the public as a result of various requests under the Freedom of Information Act (FOIA). These requests, in effect, were seeking to overturn a 33-year-old court injunction which prevented CMS from giving public access to the data.
That original injunction came from a lawsuit filed by the American Medical Association (AMA) and the Florida Medical Association in 1981 to prevent then President Jimmy Carter’s administration from publishing these data files.
A year ago (May 2013) a federal judge lifted that 33-year ban.
This week the data set was released. All billion plus data points.
The data set included the names and work addresses of about 880,000 physicians and other health care providers. It also provides how much each physician received of the $80 billion paid out under Medicare Part B Fee-for-Service Program for 6,000 different types of services (per the National Provider Identifier (NPI), Healthcare Common Procedure Coding System (HCPCS) code system).
But wait, there’s still more.
In addition to names, addresses and dollar amounts, the data set also gives the number of services, average submitted charges and standard deviation in submitted charges, average allowed amount and standard deviation in allowed amount, average Medicare payment and standard deviation in Medicare payment, and a count of unique beneficiaries treated.
Use or Misuse?
CMS has been using this data for years to compare hospitals. Last May, for example, the agency released hospital charge data allowing consumers to compare charges for common inpatient and outpatient services by hospital and location.
But now the public can mine and manipulate the data. National Public Radio said that CMS was relying on a form of “crowd sourcing” to uncover potential fraud, waste or abuse. The way in which the data is organized, virtually anyone will be able to compare physicians (who accept Medicare patients), specialties, locations, types of medical services and procedures delivered, Medicare payment amounts, and submitted charges.
Jonathan Blum, Principal CMS Deputy Administrator/CMS
Principal CMS Deputy Administrator Jonathan Blum, said that the information would allow for a more informed debate about appropriate Medicare payments for particular services. He cited the example of The Wall Street Journal which had used similar payment information to identify and report on a number of instances of Medicare fraud, waste, and abuse, using Medicare payment data.
Blum also said the information will allow a more informed debate about the appropriate Medicare payment for particular services.
Notably, the AMA and thousands of individual physicians are concerned that the plaintiff’s bar, payers, reporters, hospital administrators or others could use the information to reduce pay or change work rules or generally bash physicians.
AMA’s Nine-Step Program for Physicians and Other Providers
The AMA provided a list of nine items of caution that physicians or other healthcare providers can use when discussing the data with either patients or reporters:
Errors — Data being released may contain errors because there is currently no mechanism for physicians and other providers to review and correct their information.
Quality — The data does not include explicit information on quality of care provided or quality measurement. It solely focuses on payment and utilization of services so it cannot be used to evaluate the value of care provided.
Number of Services — Residents, physician assistants, nurse practitioners and others under a physician’s supervision can all file claims under that physician’s NPI; the data may not properly detail the services performed and who performed them. Additionally, there are several instances in which it can appear that two surgical procedures were done when in fact there was only one. For example, when there are co-surgeons or an assistant at surgery, the procedure should be counted as only one surgery, not two.
Charges vs. Payment — Medicare and other payers pay fixed prices for services based on fee schedules; therefore the amount paid to physicians is generally far less than what was charged and is not an accurate portrayal of payment.
Patient Population — The data is an incomplete representation of the services physicians provide, as it is not risk adjusted. Additionally, it does not include care for private insurance patients or Medicaid beneficiaries, making it a limited view of the patients a physician cares for.
Site of Service — Payment amounts vary based on where the service was provided. Medicare pays physicians less for services provided in a hospital outpatient department than for services in the physician’s office. However, for services in the outpatient department, another payment is made to the facility to cover its practice costs so that, in reality, the total costs to Medicare and to the patient may be higher when a service is provided in a facility setting.
Provider Comparisons — There is a lack of specificity in specialty descriptions and practice types in the data, which could be misleading when making comparisons between physicians. In some cases, physicians who appear to have the same specialty can serve very different types of patients, thus impacting the mix of services provided.
Missing Information — The data does not account for patient mix and demographics or drug and supply costs.
Coding and Billing Changes — Any analysis using the data should take into account changes in Medicare’s coding and billing rules that may be different over time and across regions of the country (e.g., local coverage determinations).
Wrestling With the Data Yourself
Charles Ornstein/Lars Klove and ProPublica
The data is, of course, available to anyone. Charles Ornstein, a senior reporter with ProPublica and Pulitzer Prize-winning writer, offered six suggestions to anyone who seeks to mine and learn from these massive data files.
Have a strategy for storing and opening the data. — This data set is big. About 10 million rows. Because of that, you won’t be able to analyze it in Microsoft Excel and you might not be able to open it in Microsoft Access. You’ll want to upload it onto a data server and analyze it in a more powerful program such as SQL or SPSS.
Know what the data covers–and what it doesn’t. — This data covers services and treatments provided by doctors and other health professionals who treated the 33 million beneficiaries in Medicare Part B in 2012. It doesn’t include expenses incurred by the 13.6 million people in Medicare Advantage plans (managed-care plans) in 2012 nor does it include any private insurance costs/payments. Moreover, this data doesn’t cover payments for inpatient hospitalizations, skilled rehabilitation, durable medical equipment or prescription drugs.
There are many reasons why a doctor may receive large payments from Medicare. — For one, the doctor may treat exclusively Medicare patients. In such cases, the doctor’s payments would naturally look larger compared to peers who also see a lot of privately insured patients (this is called a provider’s payer mix). Another explanation is that the doctor may provide services that are reimbursed at higher rates than typical office visits. A third explanation is that the provider may have other professionals billing under his/her Medicare number, which is allowed in some circumstances. Of course, there may be other reasons that raise questions of fraud, but don’t just assume that because a number is large, a doctor has done something wrong.
Quantity and quality are not the same. — Doctors who perform a lot of surgeries generally have better outcomes than those who perform fewer procedures. But because of the payer mix problem mentioned in the last paragraph, you won’t necessarily know from the Medicare data alone how many procedures a doctor performs across his practice. As health care data expert Fred Trotter notes, a surgeon who has “low volume” in this data might be actually be doing the procedure a lot, but just for commercial payers primarily.
Not everyone can be compared head to head. — It doesn’t make sense to compare the billings/services provided by a neurologist to those of a primary care doctor.
Medicare coding and billing is complex. — Take the time to familiarize yourself with…billing codes, some of which seem almost identical. Medicare also has a series of adjustments to the data that take into account where the service is being performed (hospital vs. office), geographic differences in costs between regions, etc.
To view the physician dataset, visit: http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Physician-and-Other-Supplier.html.