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Transparency: Still a righteous concept, but we are seeing a grossly flawed execution
Recently, CMS released physician-level financial data to the public as a result of requests under the Freedom of Information Act. In 2013, a federal judge lifted a more than 30-year ban preventing public release of the Carrier Standard Analytical File. This file contains information relating to individual physicians including their name, work address, Medicare Part B payments and services provided.
CMS said the unprecedented release of the information was intended to help consumers make better choices. Clearly, the public availability of such data represents a continued progression of transparency in health care pricing and economics.
Transparency
On the surface, transparency is generally a good thing, as opposed to secrecy and naiveté. But below the surface, transparency that provides insufficient information to objectively and accurately interpret the data can actually be dangerous, harmful and set up the potential for misuse. In 1981, there was a court injunction that resulted from a lawsuit filed by the Florida Medical Association and the American Medical Association to prevent the Carter administration from publishing similar data. What is the big deal?
Scott D. Boden
First, because these data only represent payments related to Medicare patients and not other payers, payments to different specialties, subspecialties and individual practices will largely be driven by the demographics of their respective patient population. That makes comparisons between specialties and even physicians hazardous and, in many cases, invalid.
Second, physicians sometimes use extenders, such as physician assistants or nurse practitioners, who can legally bill under the physician's number thus appropriately inflating their payments but without regard for the additional costs (i.e., salary, benefits and staff) of the advanced practice provider.
Third, the data doesn't contain information on the total cost of care for the patient so situations where physician payments are high might actually represent a scenario where the total Medicare expenditure is substantially less, and thus more favorable for CMS and patients. Fourth, the data set does not include information on risk adjustment which can greatly affect the cost of care, likelihood of complications and ultimately physician payments.
Another piece missing from the payment information data set is the physician expenses associated with generating these services and can give a misleading impression of physician income. Finally, there is no information provided about quality of care and thus the most important metric, value, is not able to be calculated with any presentation of these data.
Relative gain in quality of life
Spine surgery is among the most complex, risky and challenging, and, thus, it has substantial physician payments associated with it. But what is not included in the newly released CMS data is any measure of the relative gain in quality of life realized by various surgical patients, and specifically the cost per quality adjusted life year— a measure of the value/benefit of the intervention to society and the patient. As a result, conclusions drawn from an incomplete and potentially inaccurate data set are not likely to enhance the public perception of physicians at a time when the bureaucratic and emotional wear and tear on physicians just trying to care for patients is at an all-time high. Moreover, many of the conclusions could provide completely wrong information to consumers by only focusing on one part of the overall health care value equation (physician payments), which is actually only a small portion of total CMS dollar expenditures (facility fees, supplies, drugs, implants and rehabilitation).
Because these CMS data files are typically too large to open in standard database programs available to consumers, it is unlikely that any individual consumer will mine this data to help “make better choices.” It is far more likely that special interest groups will “cherry pick” out trends and subsets of data that support their interests and raise more questions than provide helpful answers.
Misuse of this type of data in the coming months and years may put our profession on the defensive, but transparency is upon us. It would behoove all physicians to understand the limitations that can accompany use of this type of data and to focus on generating a more complete data set that would be useful to consumer and health policy decision-making. I am concerned that in this case transparency is still a righteous concept, but we are seeing a grossly flawed execution.