| NEW YORK, April 9
NEW YORK, April 9 In 2012, an enterprising
ophthalmologist in south Florida received $20.8 million in
Medicare payments, the highest amount the government health plan
for the elderly paid an individual provider that year, according
to a preliminary analysis of federal data.
A family-practice doctor in Maryland may have received an
average of more than $86,000 per patient that year, according to
a Reuters review of the data. And a California laboratory
apparently received $190 million, the most Medicare paid a
single entity in 2012.
After decades of litigation and over the strenuous
objections of the American Medical Association, the leading U.S.
doctors group, the federal Centers for Medicare and Medicaid
Services (CMS) on Wednesday made public for the first time how
much Medicare pays individual doctors.
The massive data release, totaling nearly 10 million lines,
also includes which medical services each of more than 880,000
physicians and other healthcare providers nationwide billed
Medicare for in 2012.
"While the data are not perfect, this is a major milestone
in healthcare transparency," said cancer surgeon Marty Makary of
Johns Hopkins School of Medicine, whose 2012 book,
"Unaccountable," argues for making public more information on
doctors and hospitals.
In addition to allowing patients to see which doctors
perform a particular procedure most frequently - often a proxy
for expertise in rare and difficult surgeries such as colon
operations - the data are expected to offer a roadmap to where
waste and fraud are most rampant not only in the Medicare
program but throughout the American healthcare system.
"If you see that a doctor is doing a procedure hundreds or
thousands of times that should be done only on a small number of
patients, you wonder," said Dr. John Santa, medical director of
Consumer Reports. "Are they committing fraud by billing for
something they're not actually doing, doing unnecessary
procedures because they're greedy, or do they practice someplace
where so many people need the procedure?"
Medicare paid physicians, physical therapists, nurse
practitioners, chiropractors and other individual providers $77
billion in 2012. About two-thirds of Medicare's total $540
billion in payments that year went to hospitals and most of the
rest to prescription drugs.
The providers on the list all participate in Medicare Part
B, which covers services from eye exams and physical therapy to
knee replacements, cataract surgery and CT scans.
Doctors are not required to accept Medicare, which covers
some 50 million elderly and disabled Americans, but most do.
Excluding pediatricians, 91 percent of U.S. doctors accept new
Medicare patients, according to a 2013 report from the Kaiser
Family Foundation, and even more continue to see existing
The data released on Wednesday include the names and
addresses of physicians who submitted claims to Medicare in
2012, along with the codes for the approximately 6,000 services
Medicare covers. It lists the number of times providers billed
for each service, the average submitted charge and how much that
deviated from the national norm.
The billing information is expected to indicate which
physicians, therapists or others claim an inordinately high
number of complicated cases. If a case is particularly complex,
Medicare allows them to add a "modifier" to the code they use
for billing and claim higher reimbursement.
"You'll be able to see back surgeons whose average bill is
$50,000 because they say almost all of the spinal fusions they
do are more complicated than the usual, and others whose average
bill is $5,000" because they rarely classify the procedures as
extra-complicated, said Santa.
According to the 2012 data, 344 clinicians each received
more than $3 million from Medicare Part B.
That alone is not evidence of fraud, experts warned. But it
can warrant additional scrutiny.
Last December, the inspector general of the Department of
Health and Human Services, CMS's parent agency, found that 303
clinicians each collected more than $3 million from Medicare
Part B in 2009, triggering "improper payment reviews" for 104.
Those reviews identified $34 million in overpayments. Three of
the clinicians had their medical licenses suspended; two were
Although CMS has had the data all along, outside healthcare
experts are eager to scrutinize it, said healthcare analyst and
Medicare expert Cristina Boccuti of the Kaiser Family
Foundation. One thing they will look for is high-volume doctors.
If some providers are billing for many more services per patient
than others in the same community, she said, it could indicate
Those experts will also be looking for regional disparities,
Boccuti said. Since the 1990s, the Dartmouth Atlas of Health
Care, a project of Dartmouth College's health policy institute,
has documented vast differences between cities in the frequency
of various medical procedures.
Doctors in McAllen, Texas, perform five times as many
coronary-bypass surgeries per 1,000 Medicare patients as those
in Pueblo, Colorado, the Dartmouth project has found. Yet
patients in high-volume cities are no sicker.
Consumer groups and media outlets have been trying to get
the Medicare physician data since Jimmy Carter was in the White
House. In 1979, after federal officials planned to release it,
the AMA and the Florida Medical Association sought an injunction
to stop them on the grounds that making the information public
would violate physicians' privacy. A federal judge in U.S.
District Court in Jacksonville, Florida, ruled in the medical
Last May, however, a judge in the District Court lifted the
ban in response to a Freedom of Information Act (FOIA) request
made by Dow Jones & Co, publisher of the Wall Street Journal,
despite the continuing opposition of the AMA.
Last week, AMA president Dr. Ardis Dee Hoven said the group
"is concerned that (the government's) broad approach to
releasing physician payment data will mislead the public into
making inappropriate and potentially harmful treatment decisions
and will result in unwarranted bias against physicians that can
After CMS was deluged with FOIA requests for the data, it
invoked a law that requires federal agencies to openly publish
"frequently requested" information.
The data are not exactly user-friendly. CMS said on Tuesday
that it would post the information on its website, www.cms.gov,
but it is not easily searchable.
Still, a determined patient could see, for instance, that a
particular physician performs an operation only one way.
Hopkins' Makary offers the example of a hysterectomy, which can
be done as open abdominal surgery, vaginally or laparoscopically
(through a tiny incision).
"When discussing your options with a physician," he said,
"that's useful information to know," since it can indicate that
the physician does not tailor procedures to patients' specific
Healthcare watchdogs are optimistic that the data will also
reveal which physicians are abusing the system by billing for
medically unnecessary procedures, which along with fraud are
estimated to account for one-third of the $2.8 trillion in
annual U.S. healthcare spending.
(Reporting by Sharon Begley and M.B. Pell; Editing by Michele
Gershberg and Prudence Crowther)