Release of reimbursement data a shaky step toward transparency

The release of Medicare physician reimbursement data earlier this year has sparked intense debate among hematologists and oncologists.

Some suggest the CMS-prepared data set — which documents Medicare services, charges and payments from 2012 for more than 880,000 health care providers in the United States — signifies a much-needed step to make the nation’s health care system more accountable and reduce wasteful spending.

“We welcome information like this becoming publically available,” Linda J. Burns, MD, president of the American Society of Hematology and professor of medicine in the division of hematology, oncology and transplantation at the University of Minnesota, told HemOnc Today. “I see this as the first step for providing transparency to the public regarding Medicare physician reimbursement.”

However, many physicians caution the data — which encompass $77 billion in Medicare payments — are incomplete, inaccurate and lack context. Because cancer is predominantly a disease of the elderly, and because chemotherapy costs are steep, high reimbursements for hematologists and oncologists may be particularly difficult to interpret.

“When I reviewed the information that was provided, I found it a little bit confusing. Maybe that’s because I’m a physician, not an economist,” Burns said. “Although there’s information, dollar amounts and Excel spreadsheets, it’s a little hard to interpret. This data set must be released with appropriate disclosures and explanatory statements for it to truly make an impact.”

HemOnc Today spoke with several physicians to gauge their reactions to the data release, the potential that reform advocates and patients could take the information out of context, and the need to link the data to quality measures.

Transparency vs. data dump

An article published in April in TheNew York Times confirmed the power of Medicare reimbursement data to uncover abuse and fraud among physicians. The article spotlighted one Brooklyn-based physical therapist who received $4.1 million in Medicare reimbursements, a figure that equates to 21 treatments per hour every day.

“This is long overdue, and there have already been a few things that we’ve learned from this data release,” Ezekiel J. Emanuel, MD, PhD, professor of medical ethics and health policy in the Perelman School of Medicine of the University of Pennsylvania, told HemOnc Today. “We’re going to easily find out who the large-volume users are, and we will easily identify fraud or suspicious activity.”

Although the data have the potential to reveal extreme examples, those cases might be rare.

“There are going to be huge outliers in the data set that aren’t going to be able to be satisfied by simple explanations,” Samuel M. Silver, MD, PhD, MACP, FASCO, professor of internal medicine at the University of Michigan and a HemOnc Today editorial board member, said in an interview. “You might find areas of Medicare abuse, but it’s not going to involve your typical provider in a typical practice.”

Others contend the data sets lack sufficient context to draw such conclusions.

The debate about the CMS data release is similar to the one regarding conflicts of interest in medical research, according to Thomas P. Stossel, MD, a hematologist and director of the translational medicine division of Brigham and Women’s Hospital.

“There’s a massively overblown mania over the transfer of value from industry to physicians,” Stossel said in an interview. “The people who promote this and who control the big databases operate under the conceit that they’re going to find the corruption that they haven’t found for the past 30 years.”

Many have expressed similar sentiments, coining the CMS data release a “data dump.”

“There’s this tendency for health care reformers and pundits to believe in utopian ideas such as, ‘If we just have enough data and we crunch enough numbers, we will come to the truth about the best way to treat patients and how to run the medical care system most economically,’” Stossel said. “That is a conceit. Human beings are not barcodes.”

‘Apples to oranges’

Physicians and medical societies have expressed concern that the reimbursement data lack enough context for proper analysis. The potential for misinterpretation may exaggerate accusations of abuse and fraud.

“This is truly a data dump without explanation as to the context of the data they are providing,” Silver said. “These are gross numbers that deal with payment issues and commodities, and nothing to do with what the practices get from Medicare for evaluation and management services.”

The accuracy of the data is clouded by the fact that one physician often stands in for his or her entire practice when billing for Medicare reimbursement. Silver said one of his colleagues was listed as billing $7.5 million, but that figure actually represented more than 1,700 physicians involved with a demonstration project.

This can be particularly problematic for physicians in larger practices, according to Richard L. Schilsky, MD, FASCO, ASCO’s chief medical officer.

“In many large practices, decisions are made internally to have most of the billing and reimbursement done under one or a limited number of physicians who are doing it on behalf of the entire practice,” Schilsky told HemOnc Today. “The billing data are not an accurate reflection of the activity of an individual physician, but rather of the practice. It’s impossible to sort that out from the data that were provided.”

Although providers received notice of the data release, they did not have the opportunity to review and correct the data before they were made public. Some critics noted the data contain misspellings and improper listing of physicians.

CMS has since released a list acknowledging limitations of the data, including the fact they are not risk adjusted and that reimbursements may vary geographically.

However, these caveats may still be inadequate.

“There are some glaring issues that remain unaddressed,” Ardis Dee Hoven, MD, president of the AMA, told HemOnc Today. “The CMS list of limitations does not mention that some of the information in the database is inaccurate. Additionally, we’ve noticed that some providers are actually missing from the database because their patient loads were divided over multiple care settings and they did not see more than 10 Medicare patients in a single setting.”

Facility fees and data from Medicare Advantage patients also are missing from the data set and might skew interpretations, Silver said.

This lack of context makes certain comparisons difficult, if not impossible.

“If someone tries to do something simple, such as compare private practices vs. hospital outpatient practices, it might appear that private practices actually have higher charges because facility fees don’t appear in this data set,” Silver said. “It’s comparing apples to oranges. It’s hard to understand how one can take a look at these data and make any comparison.”

The release of these data may render negotiations between hospitals or large practices and private insurers based on chargemasters more difficult, Silver said.

CMS released a fact sheet with potential uses for the data, including comparing services provided and payments received among providers, and examining variations in the patterns and provisions of services. However, these types of comparisons may cast doctors in a bad light, Schilsky said.

“People who have biases about physician behavior may delve into this data set and make observations and find trends and report on findings that may be completely inaccurate,” Schilsky said. “You can do all the analysis you want on inaccurate data, and it will still be an inaccurate analysis.”

Hem/onc data skewed

The data may be particularly convoluted for hematologists and oncologists.

ASCO estimated that 50% to 70% of the Medicare reimbursement hematologists and oncologists receive is for chemotherapy and other treatment costs.

“Oncologists use some of the most expensive drugs on the market, and there is going to be a large overhead to purchase these drugs in advance in order to provide them to patients,” Schilsky said.

AMA also is concerned about high reimbursement rates due to drug costs.

“CMS did not point out that reimbursement for the cost of these drugs had been lumped in with payments for physician services, making a lot of oncologists look like they were making millions of dollars from Medicare even though most of the money was essentially passed through to drug companies,” Hoven said. “Even those stories that do mention the pass-through payments made for these drugs often imply that physicians are selecting more expensive drugs to collect higher overhead allowance payment rather than to address patient needs.”

Hematologists and oncologists usually perform fewer procedures than other specialists — such as cardiologists or gastroenterologists — and that also may affect the data, Burns said.

Further, ASCO projects that 60% of cancer patients are eligible for Medicare, a percentage that skews higher than practices in other specialties, such as rheumatology or endocrinology.

According to CMS, hematologists and oncologists have the highest average Medicare-allowed amount per physician — $463,844 — and that figure might include Part B-covered prescription drug costs. Radiation oncologists are second on the list with a $458,222 allowance, and medical oncologists are fourth with a $390,992 allowance.

In a list of provider specialties with the highest Medicare payments, hematologists and oncologists rank eighth.

Yet these aren’t the numbers that should be evaluated to determine progress in care, Stossel said.

“The idea that medical care would be perfect if we just had all the information that was out there, enabling us to get rid of the bad intentions, all of which have to do with greed, is a utopian pipe dream,” Stossel said. “What people should be keeping their eye on is the track record. Huge progress has been made in hematology and oncology. There’s a lot of room for improvement, but it’s not going to come from pointing fingers at people.”

Concerns for patients

Due to the complexities of the data, patients may question the quality of care they receive based on the figures alone, or they may believe an inaccurate interpretation reported by the lay press.

“Based on the broad media coverage of the data’s release, it is probable that some patients will review the data and make care decisions based on it even though the information may be quite misleading,” Hoven said. “As for front-line clinicians and physicians, they may be forced to spend valuable time answering questions about the data — time they could be using to provide quality care. It is also possible that some patients will change physicians, leaving the care of those doctors who are most familiar with their cases, due to unfounded conclusions about relative costs or the expertise of different physicians.”

This is particularly concerning for cancer patients.

“A patient may be seeing a doctor for their cancer for 5 years, and all of a sudden there are some data that raise a question about the performance of their physician,” Schilsky said. “It may threaten the bond of trust one has with their physician, and it may be based on completely erroneous and inaccurate information. We don’t want patients to be stressed in that way when they’re going through cancer treatments.”

However, Stossel said patients are unlikely to look at the data, and that the likelihood that someone will show up at an appointment with questions about the reimbursement rates is slim.

“These data are for politicians, pundits, muckrakers and lawyers,” Stossel said. “All of this stuff benefits those people, it doesn’t benefit patients — and it certainly doesn’t help doctors.”

Many critics also emphasized the data set says little about quality of care.

“The most important concern I have is that the data do not in any way indicate the quality of care that’s provided by individual physicians, nor that the patient receives,” Burns said. “The quality of care delivered has to be the number one thing that consumers and physicians care about.”

CMS acknowledged this point in a brief written statement provided to HemOnc Today.

“This data only presents one aspect of the delivery of care in the Medicare program – resource utilization for physicians and other health care professionals within fee-for-service. While utilization data is a valuable resource for stakeholders, quality information is also important,” the statement read.

Evaluating patient volume according to the data might reveal a fine line between quality care and abuse.

“Big-volume producers can be both positive and negative,” Emanuel said. “It’s positive in the sense that there are known associations between high volumes and better outcomes in standardized practices. But we also know that, at some point, you get to the tipping point where what you’re doing is just a mill. It’s not real patient care, you’re just sending patients through to collect money.”

Types of claims per physician also can be analyzed for quality, Emanuel said. For instance, one could evaluate the number of lines of chemotherapy for metastatic solid tumors, or identify high rates of ICU or hospital stays vs. hospice care at the end of life.

CMS has initiated efforts to report on quality of care with the Physician Quality Reporting System (PQRS), a voluntary reporting assessment. According to its website, CMS will offer incentives and payment reductions to physicians who report satisfactory measures.

However, these programs also have limitations.

“Participation in PQRS and other CMS quality programs indicates a commitment to quality care but does not provide information about the actual quality of care provided,” CMS wrote on its website. “At this time, Physician Compare only includes information about whether individual physicians and other healthcare professionals participate in PQRS, not about their performance.”

CMS plans to post physicians’ performance ratings on its website by 2015, as well as create payment adjustments for providers who do not report satisfactory quality measures.

The Qualified Entity program — another CMS measure — currently consists of 12 US health care organizations that provide publically available performance reports generated by comparing Medicare data with other claims data.

Yet physicians should still prepare themselves for questions.

“Doctors should be able to defend what they do,” Stossel said.

Living with the data

Medical societies that have released statements about the data release have not argued for the removal of the data set; rather, they called for the data to be amended and improved for context.

“We would very much like to work with CMS as a professional society to offer our expertise in helping them to ensure that our data is accurate and interpreted with the right context,” Schilsky said. “We want to ensure that the next time they do this, it will be information that will actually be helpful to people instead of just generating a lot of misinformation.”

AMA also released talking points for physicians in case patients ask questions. Despite reports of physicians earning millions from Medicare, the association found that 75% of providers received less than $85,000 yearly, and that the median payment is slightly more than $30,000.

AMA also urge all physicians to check the database to ensure their data are correct, and the association created a resource website through which physicians can report inaccuracies or concerns to CMS. However, CMS has denied requests to create a system to amend inaccuracies, Hoven said.

Despite the criticism, the data — even if flawed — might be better than nothing.

“Physicians have been fighting these data for 30 years,” Emanuel said. “There may be issues with some of the data, but overall it’s better to have the data out there and analyzed than bemoan the context. We — collectively, as a physician community — have been trying to hide these data. It’s better to have the data out there. It’s more ethical.” – by Alexandra Todak

References:

AMA. Release of physicians’ Medicare claims data. Available at: www.ama-assn.org/ama/pub/advocacy/topics/release-of-physicians-medicare-claims-data.page. Accessed on June 6, 2014.

CMS. Fact sheets: HHS releases physical-level Medicare data. Available at: www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2014-Fact-sheets-items/2014-04-09.html. Accessed on June 6, 2014.

CMS. Historic release of data gives consumers unprecedented transparency on the medical services physicians provide and how much they are paid. Available at: www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2014-Press-releases-items/2014-04-09.html. Accessed on June 6, 2014.

CMS. Medicare fee-for-service provider utilization and payment data physician and other supplier public use file: A methodological overview. Available at: www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Physician-and-Other-Supplier.html. Accessed on June 6, 2014.

Creswell J. The New York Times. One therapist, $4 million in 2012 Medicare billing. Available at: http://nyti.ms/1it5pdo. Accessed on June 6, 2014.

For more information:

Linda J. Burns, MD, can be reached at American Society of Hematology, 2021 L St. NW, Suite 900, Washington, DC 2003.

Ezekiel J. Emanuel, MD, PhD, can be reached at Perelman School of Medicine, University of Pennsylvania, 122 College Hall, Philadelphia, PA 19104; email: vp-global@upenn.edu.

Ardis Dee Hoven, MD, can be reached at American Medical Association, AMA Plaza, 330 N. Wabash Ave., Chicago, IL 60611-5885.

Richard L. Schilsky, MD, FASCO, can be reached at American Society of Clinical Oncology, 2318 Mill Road, Suite 800, Alexandria, VA 22314; email: richard.schilsky@asco.org.

Samuel M. Silver, MD, PhD, MACP, FASCO, can be reached at University of Michigan Medical School, 4118 Med Sci 1, SPC 5624, 1301 Catherine St., Ann Arbor, MI 48109-5624; email: msilver@umich.edu.

Thomas P. Stossel, MD, can be reached at Brigham & Women’s Hospital, Harvard Medical School, 1 Blackfan Circle, Karp Family Research Building, 6th Floor, Boston, MA 02115; tstossel@partners.org.

Disclosure: Burns, Emanuel, Hoven, Schilsky, Silver and Stossel report no relevant financial disclosures.