Revelation! The Personal Details Of How Much Medicare Pays Doctors

How much Medicare pays doctors. Dan Keating, Cristina Rivero, Kat Downs and Emily Chow 

The Washington Post.

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Searchable interactives: Check how much Medicare reimbursed your provider in 2012. 
The New York Times and The Wall Street Journal.

The top biller has history of scrutiny from the feds. "The doctor who bills the most for Medicare in the country is a South Florida ophthalmologist whose offices were twice raided last year by the FBI and whose generous political contributions and cozy relationship with New Jersey Senator Robert Menendez are under investigation by federal public corruption prosecutors, a New York Times analysis of Medicare data shows. Data released Wednesday by the Centers for Medicare and Medicaid Services show Dr. Salomon E. Melgen, 59, who moved to Florida from the Dominican Republic in the late 1970s, received $21 million in Medicare reimbursements in 2012 alone. The doctor billed mostly for Lucentis, a medication used to treat macular degeneration made by a company that pays generous rebates to its doctors. The release of the Medicare figures was the latest in a series headline-grabbing disclosures that have dogged the doctor since January of last year....Dr. Melgen's lawyer warned against presuming that the doctor's high bills to Medicare meant he was engaged in fraud. In a statement released late Tuesday, his lawyer said the large reimbursements from the Centers for Medicare and Medicaid Services, known as CMS, were easily explained: The doctor has a big practice." Reed Abelson and Sarah Cohen in The New York Times.

The arguments for releasing the data. "While drug and hospital costs have been scrutinized, less attention has been paid to doctors' fees, which accounted for about 12 percent of Medicare's budget in 2012. Making the data available may allow the public and researchers to better identify fraud and waste by doctors in the $604 billion Medicare system. The data could also put more heat on doctors who engage in self-referral -- ordering up tests and procedures that are performed in their own clinics or in those in which they have a financial interest. The data release has been lauded by consumer groups seeking to spotlight possible fraud or overuse and criticized by physicians, including the American Medical Association, whose head has said misinterpretation could ruin doctors' careers. Medicare payments to doctors were kept from the public after medical associations argued in the early 1980s that their release would violate physicians' privacy. Last May, a federal judge lifted a 33-year-old injunction on the data following a lawsuit by Dow Jones & Co." Shannon Pettypiece and Alex Wayne in Bloomberg.

What is self-referral, and why does it matter? "As the data are sliced and diced in coming months, some of the most revealing story lines will undoubtedly involve physician groups that excel at what's called self-referral -- the practice of sending patients for tests and procedures that are performed in the doctor's own office or at an affiliated clinic, Mitchell says. These services include in-house pathology labs to analyze prostate and skin specimens; imaging machines such as MRI and CT scans to check for broken bones, and even high-end radiation devices to treat cancer patients in a urologist's or oncologist's office. While self-referral is illegal under federal law -- so that doctors won't put pay above patients in making medical decisions -- several exemptions in the statute have permitted the practice to flourish in the past decade. Multiple peer-reviewed studies on specialties that are rich in procedures, including orthopedics and urology, have shown that doctors with a vested interest order many more tests and procedures than doctors who have no financial stake in providing the ancillary services." Peter Waldman inBloomberg Businessweek.

And here's why journalists will cheer. "For investigative journalists, any information that sheds more light on doctors' financial incentives to do controversial medical procedures will be helpful. Until now, we've relied on glimpses of physicians' wealth, gleaned from such sources as property records, divorce filings, and nonprofit tax returns, to give a picture of how lucrative it is for them to do certain medical procedures. The Medicare pay data should provide a much clearer and more direct picture of the income they get from their work." Peter Waldman in Bloomberg Businessweek.

Doctors group's arguments against the release of the data: Misinterpretation, privacy and errors. "The AMA has warned that the data could contain errors, and in some cases, one doctor's billing number may have been used by multiple support personnel for billing purposes. In addition, the billing figures reflect what a doctor receives in payment but does not show the actual profit after paying for equipment, support personnel and malpractice insurance. For some procedures, the overhead can reach three-quarters or more of the payment amount. Many of the highest billers, for example, were in fields with unusually high expenses, and that was likely to limit their personal share of the money." The Washington Post.

An example of the data's limitations: Many costly items aren't lucrative to physicians. "For instance, the 350 highest-paid ophthalmologists performed more than $1 billion worth of services. But only four commonly used eye drugs, including $160 million worth of the biologic medicine Lucentis for macular degeneration, represented more than 20% of those fees. Doctors must buy such drugs upfront, and many earn low margins on their use. At the same time, however, some procedures performed by ophthalmologists have come in for scrutiny. In 2013, CMS cut payments for cataract surgery by about 13%, largely because the old, higher rates didn't reflect that the procedure had gotten faster." Christopher Weaver, Tom McGinty and Louise Radnofsky in The Wall Street Journal.

Background reading: An effective eye drug is available for $50. But many doctors choose a $2,000 alternative. Peter Whoriskey and Dan Keating in The Washington Post.

AMA concerned, but won't fight the data's release. "The American Medical Association (AMA) won't go to court to block the Obama administration's planned release this week of previously undisclosed Medicare data. The AMA remains concerned about the privacy implications for physicians, an official with the organization told The Hill on Tuesday, but it won't seek a legal injunction to stop the release." Jonathan Easley in The Hill.

A long-simmering debate indeed. "Health officials have debated releasing the data for decades, said Gail Wilensky, former Medicaid program director under President George H.W. Bush. Opponents of releasing the information said people may not understand how to use it. In the 1990s, she said, hospitals made the same argument when required to release mortality rates....Transparency outweighs potential damage, she said, adding there should be a fast way for providers to correct errors." Meghan Hoyer and Kelly Kennedy in USA Today.

Beyond the ratings: More tools coming to help you pick your doctor. Charles Ornstein in ProPublica and the Los Angeles Times.

Other Medicare reads:

U.S. insurers still expect cuts in Medicare payments in 2015. Caroline Humer in Reuters.