This has been a fraught week for physicians
as the CMS let loose a database of Medicare
payments that allows the media and the public to scour the numbers for signs of fraud and abuse by individual providers. But doctors' responses to the release had much to do with their own circumstances, and some are even welcoming it.
Dr. Michelle Eads faced April 9 without any apprehension. That was the day the CMS disclosed $77 billion in payments made in 2012 to 880,000 individual doctors and other providers. None of it went to Eads, who opted out of Medicare in 2003.
“I'm happy not to be in that mess,” said Eads, whose Pinnacle Family Medicine in Colorado Springs, Colo., is a cash-only solo practice.
Dr. Stephen Brotherton, an orthopedic surgeon based in Fort Worth, Texas, said the “water-cooler talk” he heard concerning the Medicare data dump was a mixture of “concern and fatalism.”
“We're concerned with what's going to happen, but there's nothing we can do about it,” Brotherton, president of the Texas Medical Association, said. “So we just buckle down and wait for the tide.”
Just listing dollar payouts can be factual but still deceiving, he said. He may give a patient with severe knee pain an injection of the anti-arthritic drug hyaluronate and receive $550 from Medicare for the effort. But, of that amount, most goes to pay for the drug itself, and Brotherton said he'll receive $60 with about half going to pay for staff and office expenses.
“So, what I'm taking home is $30,” Brotherton said.
He also recalled how the city of McAllen, Texas, was unfairly identified, in his view, as a free-spending Medicare market without taking into account the context of its demographics.
“Rural Texas is a completely different micro economy,” he said. “You have people who let disease upon disease, injury upon injury pile up who finally see a doctor when they hit 65.”
Brotherton suggested that the CMS take should now itemize the payments to physicians-especially for specialists-to identify how much of the total went for drugs, braces or a prosthesis, how much went for overhead, and how much the doctor collected.
“In Texas, only 58% of doctors are taking Medicare,” Brotherton said. “If it was such a boon, you'd see more people taking Medicare-mostly, we lose money on it.”
Dr. Richard Johnston is the chief physician officer and executive vice president of USMD Holdings, an Irving, Texas-based integrated healthcare system that is physician led and publicly traded. It includes a Medicare Advantage plan, a private gain-sharing accountable care organization, and a Medicare shared-savings ACO.
“Most of our adult medicine docs are doing population health and not straight fee for service,” Johnston said, so the Medicare data release is not really an issue for USMD's 215 physicians and 68 nurse practitioners and physician assistants.
His organization's Medicare Advantage and ACOs have closely watched quality and cost metrics. If it looks like a physician is overbilling or running up high costs, they have some explaining to do.
“This is the way we're brought up-not to veer off,” Johnston explained.
That said, Johnston said he's not sure what the Medicare data release will accomplish. When he had his own internal medicine practice, 60% of his Medicare reimbursement went for overhead expenses which would not be apparent by the Medicare data release.
“I think it's important to be transparent,” he said. “But I don't think patients could look at this data and truly make a decision on quality and efficiency.”
Johnston said he expects the data will be sensationalized and many physicians will catch some flack. “In some cases, they'll deserve the flack,” he added.
Consumer advocates, meanwhile, argue that it's the responsibility of the physicians to explain the nuances of what they collect from the program.
“We deserve to have this data as taxpayers,” said Leah Binder, president and CEO of the Leapfrog Group coalition of major employers and healthcare purchasers. “I think it's a breakthrough moment and very important to the future of our healthcare system,” she said.
Dr. John Santa, medical director for Consumer Health Choices, a division of Consumer Reports, agreed. “Patients simply deserve to have as much or more information than industry has, but they have a lot less,” Santa said.
Santa was previously the medical director of Blue Cross Blue Shield of Oregon and he encountered frequent cases of “aggressive billing” which were not necessarily crooked but they weren't appropriate either. A frequent occurrence was to perform a four-view diagnostic mammogram for patients who came in for a two-view screening. “Patients need to understand what a mess this is and that they're paying for this mess,” Santa said. “Fee for service is bankrupting us.”
Dr. Thomas Yackel, an associate professor and chief health information officer at Oregon Health Science University, called the release “a good thing” even if the raw data in itself is not that useful at first glance. The challenge he said is to use the data to begin to determine true costs.
“Cost is not just difficult for the public to determine, it's often difficult to determine from inside the organization,” Yackel said. “How much does it cost? Not how much does the patient pay or what do we charge? But how many resources do we consume when we run this test? Getting that data is very difficult.”
Dr. Bernd Wollschlaeger's Aventura Family Health Center is a paperless, patient-centered medical home practice he runs in Miami Beach with a physician assistant. Until 2012, he used to run a cash-only practice like Eads in Colorado Springs.
He said he began to take Medicare at the request of his patients and also other third-party reimbursement from previously uninsured patients who were able to gain coverage under the Patient Protection and Affordable Care Act.
According to Wollschlaeger, the release of this data is a long-overdue, positive development. The U.S. is entering an era of more accountability and transparency in all aspects of people's personal and professional lives and “medicine cannot be excluded,” he said.
“I do have a sense of resentment that there are physicians who use Medicare as a credit card,” he said. But, he added, “people should not throw all 880,000 physicians in one pot because 4,000 physicians bill more than $1 million each.”Follow Andis Robeznieks on Twitter: @MHARobeznieks