By releasing to the public a data set revealing what Medicare pays individual doctors, the Centers for Medicare & Medicaid Services says the transparency will help weed out fraud and prevent billing abuse, but physicians are crying foul.
“We believe that the broad data dump (Wednesday) by CMS has significant shortcomings regarding the accuracy and value of the medical services rendered by physicians," said Ardis Dee Hoven, MD, president of the AMA, in a statement. "Releasing the data without context will likely lead to inaccuracies, misinterpretations, false conclusions and other unintended consequences."
On Wednesday, CMS posted on its website a data set it created 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 (FFS) program and the amount that Medicare paid providers for those services.
According to CMS, more than 880,000 distinct providers across 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.
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 data set does not include information for hospitals, nursing homes or suppliers of durable medical equipment.
The data identifies individual providers using their National Provider Identifier (NPI) and the specific services they furnished using Healthcare Common Procedure Coding System (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)
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.
"Part of our strategy is to make the data more public, more accessible, to help the public find patterns of spending that could be wasteful and might not be in beneficiaries' best interests," said Jonathan Blum, CMS’ principal deputy administrator during a press briefing Wednesday. He also noted that researchers and members of the media would likely help spot outliers and alert the agency to areas that need to be examined.
He did caution that conclusions shouldn't be drawn about specialties such as oncology in which expensive drug therapy tends to be the treatment of choice. "You have to be careful to say, 'That's wrong.' Obviously it's the treatment of choice," he said.
The ease of drawing the wrong conclusions is one of the reasons physicians’ organizations are so upset.
In the AMA’s statement, Hoven said that CMS should have provided “reasonable safeguards” to help the public understand the limitations of the data, and in a statement of its own, the Medical Group Management Association cautioned about the “unintended consequences” of not providing appropriate context.
"This release could result in patients making decisions about their care based on faulty assumptions about physicians,” said Susan Turney, MD, MGMA president, in the statement. “Claims data are not a proxy for quality, especially when provided in isolation, from a single payer.”
Protests from the industry are not deterring CMS’ efforts to be more transparent. Niall Brennan, acting director at CMS' Offices of Enterprise Management, said during Wednesday’s press briefing that the agency expects to release updated hospital charge data in the next six to eight weeks.