Doc data release sparks dissent

By Frank Irving
01:51 PM
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CMS sees it as transparency while AMA argues it lacks context

CMS officials say a new data set identifying physician payments and services performed will help prevent fraud and abuse. Physician advocates say their constituents should have been allowed to verify the data before its release.

The Department of Health and Human Services today released a data set containing information on the number and type of healthcare services individual physicians and other providers furnished in 2012 under the Medicare Part B fee-for-service program.

The data set, created by the Centers for Medicare and Medicaid Services and posted on its website, also includes the amount that Medicare paid providers for those services.

More than 880,000 distinct providers in all 50 states, the District of Columbia and Puerto Rico collectively received $77 billion in Medicare payments for approximately 6,000 discrete services in 2012, according to CMS.

The agency derived the data set from the Physician/Supplier Part B Claims File, which contains final-action FFS claims submitted by physicians and other non-institutional providers, such as non-physician practitioners, ambulatory surgical centers, clinical laboratories and ambulance providers. The set does not include information for hospitals, nursing homes or suppliers on durable medical equipment.

The data identifies individual providers using their National Provider Identifier and the specific services they furnished using Healthcare Common Procedure Coding System, or HCPCS, codes.

For each provider and service, the data set also shows:

  • Total number of services furnished
  • Provider's average charge
  • Average Medicare payment
  • Average Medicare-allowed amount (sum of Medicare's payment and any deductible or coinsurance owed by the beneficiary)

HHS Secretary Kathleen Sebelius, in a prepared statement, said the data release would give consumers "insight into the Medicare portion of a physician's practice" -- the services they provide and how much they are paid. She also noted that the data would be valuable to researchers and policymakers.

However, the nation's largest physician group, the American Medical Association, while acknowledging the need for patients to have access to transparent information to make decisions about care, took issue with the release.

"We believe that the broad data dump today by CMS has significant short-comings regarding the accuracy and value of the medical services rendered by physicians," said Ardis Dee Hoven, MD, president of the AMA. "Releasing the data without context will likely lead to inaccuracies, misinterpretations, false conclusions and other unintended consequences."

Jonathan Blum, principal deputy administrator at CMS, said researchers and members of the media would likely help spot outliers. "Part of our strategy is to make the data more public, more accessible, to help the public go find patterns of spending that could be wasteful and might not be in beneficiaries' best interests," Blum explained.

CMS noted that no patient-identifiable data has been released. In addition, CMS said it did not include information in cases where a provider furnished 10 or fewer units of a particular service to ensure the confidentiality of patient-specific information.

Nonetheless, Susan Turney, MD, president of the Medical Group Management Association, cautioned about "unintended consequences" of the data release and the effect it could have on Medicare beneficiaries. "This release could result in patients making decisions about their care based on faulty assumptions about physicians. Claims data are not a proxy for quality, especially when provided in isolation, from a single payer," she said.

Turney also expressed concern on the part of MGMA that releasing physicians' financial data and NPI could make them susceptible to fraud. "Physicians should have had the opportunity to review the data before it was made publicly available in order to modify or appeal any inaccuracies,” she continued.

Blum noted that conclusions shouldn't be drawn about specialties such as oncology in which expensive drug therapy tend to be the treatment of choice. "By law, we pay for those drugs through the physician fee schedule, so you'll see physicians high on the relative scale due to those payments for very expensive drugs," Blum explained. "You have to be careful to say, 'That's wrong.' Obviously it's the treatment of choice."

He continued, "If it turns out that we see more procedures, more drug spending, in one part of the country without necessarily seeing differences in quality or satisfaction of care, that's an important question for us to be asking."

Niall Brennan, acting director at CMS' Offices of Enterprise Management, said the agency is confident that the data release will result in better quality of care over time at lower cost.

As a complement to the physician-data effort, Brennan added that CMS plans to release updated hospital charge data in the next six to eight weeks.