Small Number of Doctors Earn Big Medicare Payouts in U.S.
By REED ABELSON and SARAH COHEN
Some doctors who take Medicare received millions of dollars each in a
single year, according to newly released data that provides an
unprecedented look at the practice of medicine in the United States.
Business Day
Sliver of Medicare Doctors Get Big Share of Payouts
A
tiny fraction of the 880,000 doctors and other health care providers
who take Medicare accounted for nearly a quarter of the roughly $77
billion paid out to them under the federal program, receiving millions
of dollars each in some cases in a single year, according to the most
detailed data ever released in Medicare’s nearly 50-year history.
In
2012, 100 doctors received a total of $610 million, ranging from a
Florida ophthalmologist who was paid $21 million by Medicare to dozens
of doctors, eye and cancer specialists chief among them, who received
more than $4 million each that year. While more money by far is spent
for routine office visits than any other single expenditure, one of the
most heavily reimbursed procedures — costing a total of $1 billion for
143,000 patients — is for a single treatment for an eye disorder common
in the elderly.
The
Medicare data — all for 2012 and the subject of an intense legal battle
— provides an unprecedented look at the practice of medicine across the
country, shedding fresh light on the treatment decisions physicians and
other practitioners make every day. It will also provide consumers with
an ability to compare doctors and treatments in a way they have never
had until now.
Fraud
investigators, health insurance plans, researchers and others will
spend weeks poring over the information about how many tests were
ordered and procedures performed for every provider who received
Medicare payments under Part B, which excludes payments to hospitals and
other institutions. The Centers for Medicare and Medicaid Services is
making the data publicly available on Wednesday. While total Medicare
spending — including hospitals, doctors and drugs — is approaching $600
billion a year, payments to individual doctors have long been shrouded
in secrecy. For decades, the American Medical Association, the powerful
doctors’ group, and others have blocked the release of the information,
citing privacy concerns and the potential for misuse of the information.
But a federal judge ruled last year that the information could be made
public.
Medicare
paid $12 billion for 214 million office and outpatient visits, most of
them described as between 15 and 25 minutes long. The practitioners —
usually doctors, but sometimes nurse practitioners, were paid an average
of $57 a visit.
Much
of Medicare spending is concentrated among a small fraction of doctors.
About 2 percent of doctors account for about $15 billion in Medicare
payments, roughly a quarter of the total, according an analysis of the
data by The New York Times. These figures exclude commercial entities
like clinical laboratories and ambulance services, which account for
$13.5 billion of the $77 billion total. Only a quarter of the doctors
are responsible for three-quarters of the spending. Medicare provided
The New York Times with an advance look at the information but requested
that individual doctors not be contacted until the data was made
public. A database, searchable by doctors’ names, is available at
nytimes.com.
“This
is actually the most useful data set that Medicare has ever released,”
said Dr. Bob Kocher, who served in the Obama administration and is now a
partner at Venrock, a venture capital firm. People will be able to see
just how many elbow surgeries a given orthopedic surgeon has performed
on Medicare patients, he said, and they will be able to better judge a
doctor’s style of practice, for example, whether a CT scan is performed
on every patient or only rarely. “You’re going to see variation,” he
said.
The
American Medical Association, which chose not to try to block the
release of the information, questioned the usefulness of these payments
to assess doctors.
“We
know there are going to be limitations,” said Dr. Ardis Dee Hoven, the
president of the association. “It’s raw claims data. This gives us no
window into quality or anything of that nature.” While patients may know
who performs a high number of procedures, like hip replacements, for
example, they will not be able to tell anything about whether the
patients needed the surgery or whether they benefited from the surgery.
What’s
more, Dr. Hoven cautioned, doctors were not able to review the data,
and some of the information being made public could be wrong.
But
the release of the information is likely to increase attention to
particularly controversial areas of spending. About 3,300
ophthalmologists, for example, were paid a total of $3.3 billion from
Medicare, according to the Times analysis. Much of the spending was the
result of an expensive and frequent treatment for a kind of age-related
macular degeneration, the leading cause of severe vision loss in the
elderly, and the cost of the drug is factored into the payments doctors
receive. Ranibizumab, known by the brand name Lucentis, is injected into
the eye as often as once a month. A cancer drug that is used as an
alternative can cost much less. Other specialists also account for large
portions of Medicare spending. Fewer than 1,000 radiation oncologists,
for example, received payments totaling $1.1 billion.
Regulators
and others are also likely to seize on some of this information to find
those doctors who perform an unusually high volume of services, raising
the question of whether every test or procedure, like the placement of a
cardiac stent, was medically necessary.
“There’s
a lot of potential for whistle-blowers and justified worry for
fraudsters,” said Steven F. Grover, a lawyer who represents
whistle-blowers who sue doctors and hospitals who they claim have
committed fraud against the Medicare program. “There’s going to be a lot
of litigation over this,” he said.
The
Office of Inspector General for the Department of Health and Human
Services, which serves as a federal watchdog on fraud and abuse for the
agency, released a report in December recommending greater scrutiny of
those physicians who were Medicare’s highest billers. The report
recommended that Medicare establish a threshold to look more closely at
the high billers. Regulators have also said they are scrutinizing the
use of high-paying codes in places including the emergency room.
Health
insurance companies, which must now rely on only the claims they handle
to look at doctors, are also likely to find the information valuable,
according to Paul B. Ginsburg, a health economist and professor at the
University of Southern California. Marrying the Medicare information to
their own information, “all of a sudden they have a lot more to work
with,” he said, in trying to better determine how an individual doctor
treats patients — ordering lots of tests, for example, or being slow to
operate. “This is going to be a very important change,” he said.
Experts
say the data must be used with caution. An individual doctor, for
example, may seem to have a high volume of services because that doctor
oversees medical residents or physician assistants but bills for those
services. Medicare patients may be only a fraction of the patients a
doctor sees.
Despite
its limitations, however, policy experts largely praised the release of
the information, arguing that this was an important step to
understanding how doctors practice medicine in this country.
“Any
time Medicare releases a lot of data, it changes the conversation in
America about transparency, about cost and quality,” said François de
Brantes, the executive director of the Health Care Incentives
Improvement Institute. “It’s more a signal from Medicare to market,” he
said.
Sheri Fink, Robert Gebeloff and Andrew Pollack contributed rep
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