Thursday, April 10, 2014

Brace Yourself for Transparency

It’s here. For the first time in 35 years (or 33, depending on which click bait headline you clicked on), the much anticipated data on Medicare payments to physicians, has been released to the public, on the historic date of April 9th, 2014. “Data trove shows U.S. doctors reap millions from Medicare”, according to the distinguished Reuters news service. The Washington Post will tell you “[e]verything you need to know about today’s unprecedented Medicare pricing data dump” and Pro Publica, which specializes in rendering doctors transparent, is announcing more tools for picking doctors coming soon, based on these data. If you want to read juicy stories about a handful of crooks who happen to have a medical license, and who were already under investigation by Medicare, click on some of the links above or below. If you want to understand what this all means to you, stay with me and keep reading.

The data released by Medicare includes the doctor’s name, address and specialty. For each physician, there is a list of CPTs performed for more than 10 patients during CY 2012, and for each CPT there is the number of unique patients billed for the procedure, the number of times the procedure was performed (or billed to Medicare), the average charge per CPT and the average payment for the same. There are over 800,000 names on the list (not just physicians), so chances are good that unless you are a pediatrician or a concierge doc, your name is on it. Of course, this is just the preliminary raw list, but given enough time and innovative efforts, many, many sub-lists will be evolving. Even before the list was released to the public, several publications with advanced media access, managed to quickly produce high-spender lists, so stay tuned to your favorite news outlet for more to come. Until then, the New York Times has the best search tool, so go ahead, look yourself up. It’s OK; everybody else is doing it.

One thing to note is that the data does not include Medicare Advantage patients, so right off the bat almost a third of Medicare patients are excluded from this data trove, not to mention the exclusion of Medicare Advantage bonuses from our newfound transparency. So if you find a geriatrician that reaped only $2,056 from Medicare, try not to worry too much. Chances are the guy or gal is fully loaded with Medicare Advantage patients. Commercial payers are obviously not on the list, but neither is Medicaid. We all know that Medicare payments are just the tip of the iceberg and doctors get additional boatloads of money from private insurance, and if we don’t know, I’m sure we will be so advised by the media in the next few days. But in the interest of full transparency, wouldn’t it be enlightening to see Medicaid’s relative contribution to doctors’ wealth? I mean defrauding the elderly is pretty bad, but defrauding hungry children, should give the upcoming three-part expose pieces so much more oomph….

On the White House blog, Todd Park is telling us that “New Medicare Data Offers Unprecedented Transparency for Consumers”.  Considering that the Medicare physician fee schedule was always public and anyone could see the price of any service in any locale, and considering that the total amount Medicare is paying out to doctors is also a fairly well known number, what is it we didn’t know? Lots of stuff. First, we didn’t have an itemized list of how much Medicare is paying each doctor for each individual service. Now that we do, we can learn, for example, that Dr. X in St. Louis has billed Medicare 200 times for venipuncture (at $3 apiece) for 100 patients and also billed for about 200 office visits for 100 patients. It seems that if you go see this doctor, you will invariably end up with a needle in your arm, so better find someone else who is not going to hurt you just because you showed up, and have all sorts of unnecessary tests done on you. See how helpful data can be to an informed consumer? Don’t worry; you won’t have to engage in such complex analysis for much longer, because journalists and unemployed technologists are busy building 4th grade literacy level tools and decision aids for us all.

But that’s nothing compared to the power of implied impropriety. There are two dollar columns in this unprecedented trove of data, one is what the doctors billed Medicare and the other is what Medicare paid. A while back Medicare released a smaller unprecedented trove of similar data for hospitals with the same two columns. That too was hailed as a new era for informed consumers who will now have the ability to choose hospitals based on the value they provide. Fast forward to today, and all that remains from that particular trove are a bunch of articles highlighting the immoral variations between hospital charge master prices and their effects on the uninsured. Since physicians’ data exhibits the same discrepancy between what is billed and what is paid, and since nobody cares to understand why and how those charges end up on claims, you can expect similar stories about uninsured people being charged “sticker prices”. On a side note though, how come people are uninsured? Isn’t it illegal to be uninsured? Shouldn’t you just head over to and get affordable insurance instead of complaining about prices for the uninsured?  Yes, you will end up with a high deductible, but you won’t have to pay sticker price, and I’m sure there will be some in-network facility within driving distance that can treat chest pain, and if there isn’t, maybe as an engaged patient, you should buy one of those iPhone defibrillators Dr. Eric Topol is using on airplanes, or was it an Android EKG, not sure. But I digress.

What else can we do, or are expected to do, with this data treasure? Well, it seems that CMS is asking all of us to grab a magnifying glass and play “Where is Waldo?” with this unprecedented trove of clues for how Medicare is being defrauded by doctors. CMS, it seems, has no ability to systematically flag the Chiropractor who bills upwards of 150 manipulations per patient per year, so it keeps paying and paying ad infinitum. In lieu of building a few cheap algorithms, why not throw the entire database out there and see if taxpayers can obtain some free fraud detection from the public at large? Sort of like the Sheriff used to put together a citizen posse to chase and apprehend criminals in the old west…. The criminals, particularly the ones not guilty of any crime, should adapt and learn how to use Big Data troves to defend themselves, with the added benefit of accelerating “trends toward large medical groups and doctors working as employees instead of in small practices”, per the Huffington Post. That is a good thing too, because dealing with organized crime is so much better for society than dealing with petty theft.

Where does this leave individual physicians? Well, you could run for the nearest rock and crawl under it until this too shall pass. Alternatively, you could start generating some educational content of your own, trying to explain to your patients what the troves of data mean, and what they don’t. You could put together more complete data, at least for your own patients, and address the clinical rationale for those completely out of context data points. You could write for larger audiences, and you could contact your local media offering to provide some balance to the tabloid stories about millionaires injecting people in the eyeballs with Lucentis.

The one thing I would recommend you don’t do, is to seize this opportunity to vent your frustrations with higher paid specialties, because the media is already doing that, and because this is exactly what they want you to do, and because in the eyes of the public there is no difference between this or that specialty. It’s hunting season for all doctors, and you will not save your neck, or your specialty, by joining in the hunt for other species. And finally, considering that the median amount of money doctors were reaping from the program for the elderly and the disabled was around $30,000 per year, I can’t help but wonder if some business decisions are not highly overdue, for some people. Just sayin’… 


  1. I fear a Kristallnacht. I really do. I've read enough about the inter-war Germany to recognized too much scary stuff. I'm heartbroken to even think that.

  2. You mention about the chiropractor who bills 150 treatments in a year, how about the chiropractor (me) who has to turn away seniors from my practice because he doesn't want anything to do with Medicare, but my profession is not allowed to bow out of the program (as are physical therapists)?

    1. What do you mean? Are Chiropractors forced to accept Medicare if they see Medicare beneficiaries?? I didn't know that...