The Two-Way
10:45 am
Wed April 9, 2014

Dose Of Caution Prescribed When Evaluating New Medicare Data

Originally published on Wed April 9, 2014 1:05 pm

The headlines about one of Wednesday's big stories — the release of data from 2012 about Medicare payment to doctors around the nation — are certainly serious sounding:

-- "Sliver of Medicare Doctors Get Big Share of Payouts." (The New York Times)

-- "Small Slice of Doctors Account for Big Chunk of Medicare Costs." (The Wall Street Journal)

-- "Release of Medicare doctor payments shows some huge payouts." (Los Angeles Times)

Here's how The Associated Press sums up the news:

"Medicare paid a tiny group of doctors $3 million or more apiece in 2012. One got nearly $21 million.

"Those are among the findings of an Associated Press analysis of physician data released Wednesday by the Obama administration, part of a move to open the books on health care financing.

"Topping Medicare's list was Florida ophthalmologist Salomon Melgen, whose relationship with Sen. Robert Menendez, D-N.J., made headlines last year after news broke that the lawmaker used the doctor's personal jet for trips to the Dominican Republic. Medicare paid Melgen $20.8 million.

"AP's analysis found that a small sliver of the more than 825,000 individual physicians in Medicare's claims data base — just 344 physicians — took in top dollar, at least $3 million apiece for a total of nearly $1.5 billion."

Watch for more on this as the day continues from NPR's Julie Rovner and the Shots blog. The figures do raise questions. As the AP notes, "about 1 in 4 of the top-paid doctors — 87 of them — practice in Florida, a state known both for high Medicare spending and widespread fraud."

But here are some cautionary thoughts from Charles Ornstein, a senior reporter with ProPublica in New York. He's posted them on Covering Health, a blog from the Association of Health Care Journalists:

"There are many reasons why a doctor may receive large payments from Medicare. For one, the doctor may treat exclusively Medicare patients. In such cases, the doctor's payments would naturally look larger compared to peers who also see a lot of privately insured patients (this is called a provider's payer mix). Another explanation is that the doctor may provide services, such as eye surgery or cancer care, that are reimbursed at higher rates than typical office visits. A third explanation is that the provider may have other professionals billing under his/her Medicare number, which is allowed in some circumstances."

The L.A. Times makes the same point:

"Federal officials cautioned against drawing sweeping conclusions about individual doctors from the numbers. High payouts do not necessarily indicate improper billing or fraud, they say. Payments could be driven higher because providers were treating sicker patients who required more treatment or because their practice was focused more on Medicare patients."

Still, the Times adds that "the data could serve as an early warning for potential waste and abuse."

The Journal has an interactive tool online that allows users to search the database "by provider name, specialty and location to see the types and number of procedures performed and the amounts paid to each provider by Medicare."

It also recaps the "long and winding road" to the release of the data, which includes a 1979 court decision that granted the American Medical Association's request to bar releasing such information. That injunction was vacated in 2013.

Note: The data do not reveal personal information about any of the physicians' patients.

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