The ACP Advocate Blog

by Bob Doherty

Thursday, April 17, 2014

A Dumb Data Dump

While I was at ACP’s annual scientific meeting in Orlando last week, the big news, unrelated to the meeting itself, was CMS’s decision to release a massive amount of data on what Medicare paid out in 2012 to each U.S. physician. 

What is now commonly referred to as the CMS “data dump” created quite a stir—reactions from ACP members ranged from angst (“Why did this happen?  How will the data be used? What will my patients think?”)  to acceptance (“What’s the big deal? I don’t mind if the public knows how much Medicare paid me, I have nothing to hide”).   The first thing that many attendees did was to download their own data, something made easy by a tool created by the New York Times to look up a physician by their last name and town (or zip code) and then extract the data from CMS’s files (working directly with the CMS data file itself is a ponderous process).   Most I spoke to thought their numbers looked “about right” to them, although a few said there were inaccuracies in their own profiles.

Did the data dump show that any particular physician was guilty of fraud and abuse?  Did it show that any particular physician was over-charging the program?  Or that that a particular physician had ordered too many tests, drugs, and procedures?  Did it provide any useful information about the quality of care provided by each physician?  Or about the kinds of patients each physician treated and how sick they were?  The answers are: no, no, no, no, and no!

It was just a raw data dump, showing how much Medicare paid out to each physician for some of their Medicare patients (patients enrolled in Medicare Advantage plans were not included), not how much physicians actually took home from Medicare (because the data did not subtract overhead, like the costs incurred by oncologists for chemotherapy drugs dispensed in their offices).   Because the data included only what it was paid out per physician, without any context or adjustment for expenses, case mix, or quality, it is simply impossible to draw conclusions from the data about the appropriateness of the care provided by any particular physician.  It certainly is not possible to conclude that any particular physician, including the outliers who received the most total dollars from Medicare, were guilty of fraud and abuse—only a court proceeding can prove a violation of law. 

Yet much of the attention in the press was initially directed at Medicare's top-paid doctors, as Fox News called them the, “344 physicians who took in at least $3 million apiece for a total of nearly $1.5 billion.”   Follow-up press coverage found that in some cases the high payments that were assigned to a single physician actually reflected payments to thousands of them.   The New York Times, in an article titled “The Medicare Data’s Pitfalls,” reported on “Dr. Jean M. Malouin, a family medicine physician at the University of Michigan Health Systems, [who] shows up as one of the top Medicare billers in the country, collecting payments of $7.58 million in 2012 for more than 207,000 patients. But Dr. Malouin directs a Medicare project that involves 1,600 primary care physicians, who each receive a small payment each month. Those payments are funneled through Dr. Malouin. The doctor’s situation is described in a website that the hospital set up on Wednesday to help explain the data to the public.”

The same article quotes ACP’s new President, Dr. Dave Fleming, on the limitations of the data. “One concern is that this is a huge data dump, and a lot of interpretation is occurring without the data actually being analyzed, with exposure of physicians who have been paid huge amounts of money. I understand the implications, but there may be very legitimate reasons as to why.”

This isn’t to say that some of the top paid doctors don’t have some explaining to do, and at least one of them is being investigated by authorities for potential fraud and abuse.  And patients might legitimately want to ask why their physician is an outlier.  Further analysis will likely show that some outliers can’t be justified because of differences in case mix or other legitimate factors.  But it is a leap too far to assume from the raw data dump that a doctor is guilty of behaving badly, never mind criminally.

The data is most useful in analyzing trends and outliers, by specialty and region, to inform public policy.  Bloomberg News has a nice chart that shows the Medicare pay-outs by specialty and not surprisingly, internal medicine as the specialty that received the most Medicare dollars, more than $8.7 million, because there are more internists treating more Medicare patients than other specialties.  The average Medicare payment per internal medicine physician, though, was only $95,466.  The top four specialties, with average payments of more than $300,000 per doctor, were hematology/oncology, radiation oncology, medical oncology, and ophthalmology.  Yet the data dump amounts for oncologists and ophthalmologists include Medicare payments for the drugs (chemotherapy, and medications for macular degeneration) physicians in these specialties typically purchase and dispense in their offices, with most of the money going to the drug manufacturers, not the doctors.  Medicare limits physicians to a 6 percent mark-up on the drugs they buy, which some suggest may itself create an incentive for physicians to prescribe the most expensive drugs.

“Doctors make a markup when they buy a drug and then use it” writes New York Times reporters Andrew Pollack and Reed Abelson . “Medicare is supposed to pay 6 percent over the average price of the drug. That percent represents a larger number of dollars for an expensive drug than for a cheap one. Retina specialists talk of colleagues who earn huge amounts of frequent flier miles by buying Lucentis using credit cards.”

Transparency is here to stay, and the American College of Physicians believes that the public has a right to know where their taxpayer dollars and premiums are going, including how much their physicians are receiving.   Such data can help shine the light on why there are variations between and within specialties, regions and individual physicians in what they are receiving from Medicare and other payers, leading to policies to address variations that are not justified.  In the right context, such data can help inform consumers about their choice of physician—if combined with reliable data on quality, outcomes, patient experiences with the care provided,  and adjusted for case mix and overhead.  Physicians should have the ability to review the data before it is released, and get corrections if it is inaccurate.

Most importantly, when raw data are released to the public on how much physicians are paid, or on the quality of care they provide, it needs to be accompanied with explanations on the usefulness and limitations of the information available.  Medicare could, for instance, have released the data to the public with an explanation that it only showed the amount paid out to individual doctors, before overhead, not how much they actually took home;  that it did not adjust for differences in the patient population being treated; that in some cases, if the billings of multiple physicians were assigned to a single physician; that physicians were not given the opportunity to review the data for accuracy and context (and seek corrections) before it went out, that the data included only traditional Medicare and not Medicare Advantage, that some specialties treat more Medicare patients than others and will therefore have higher average billings, and that the data are most useful for research on trends to inform public policy, not for making a judgment about an individual doctors’ charges or quality or fraud and abuse. 

By not doing so, Medicare made the data less useful than it could have been, unfairly tarred some physicians, and mislead the public.  The government needs a smarter approach to transparency than just dumping raw data without context on the public and physicians.

Today’s questions: what do you think of Medicare’s data dump?  Have your patients asked you about it? What are you telling them?  Have you looked at your own data—and is it accurate?

Tuesday, April 1, 2014

A Banner Day for U.S. Healthcare

When the clock struck midnight last night, the United States saw something it hasn’t seen in a very long time: bipartisan consensus to make the health care system better.  After first voting for another Medicare SGR patch, the Senate came back late in the evening, and with the support of Senate Majority Leader Harry Reid and Minority Leader Mitch McConnell, the Senate reconsidered its early vote for a temporary one-year patch and instead voted out the bipartisan and bicameral permanent SGR repeal and Medicare physician payment reform bill previously agreed to by the Senate and House Medicare committees.  On the other side of the Capitol, Speaker John Boehner and Minority Leader Nancy Pelosi agreed to immediately enter into negotiations with the Senate on how to pay for the bill.  “We blew it last week when we used a parliamentary sleight-of-hand to pass the patch” Speaker Boehner told the Washington Post.  “Patients and their doctors deserve better.  This time, we will do the right thing and find a way to get an agreement with the Senate on permanent SGR repeal.  Yes, it will be tough, but that is why we are here, isn’t it?”

The other sea change occurred when it appeared that Republican leaders took heed of the latest Obamacare enrollment numbers and dropped their insistence on repealing the law.  “Look, we can count the numbers” said one highly placed GOP strategist” in a phone call with this blogger.  “Despite the debacle with the government website, it is now looking like enrollment in Obamacare’s marketplace plans may meet or exceed the original target of 7 million.  All along, the GOP strategy has been based on the idea that people will vote with their feet and reject Obamacare, with a nudge from us” he continued, “but they haven’t.  Total Obamacare enrollment, including the marketplace plans, young adults on their parents’ plans, and Medicaid, may fall between 13 and 16 million people this year.  And it appears that more than 9 million of them were previously uninsured, and that number will grow as more sign up for Medicaid during the year.  And fewer than one million of the people whose insurance was ‘canceled’ actually lost coverage.  So yeah, we get it, we won’t win by kicking all of these people off Obamacare.  We have our work cut out for us though in persuading our Tea Party base to let go of repeal.”  On the record, Republican leaders were more muted, with Senator McConnell noting that he was hearing from large numbers of Kentucky residents who were benefiting from Obamacare, “Yes, I hear them.  I still think Obamacare is a mistake—we could have helped a lot of folks with a lot less money.  If it was up to me, I would start over and pass something different.  But it is clear now that the law is here to stay, so I will reach out to my Democratic friends and President Obama to seek common ground on how to make it better. “

A relieved but chastened President Obama said “Make no mistake, I blew it when I told everyone they could keep their health plans.  I blew it by the disastrous roll-out earlier this fall.  Yet somehow, people still signed up in droves, exceeding my own downsized expectations.  We can make it better though, and today I pledge to reach out to my Republican and Democratic friends in Congress to find bipartisan approaches to improve it.”

Okay, April Fools—most of the above didn’t happen.  The Senate joined the House in passing a one-year SGR patch instead of permanent repeal and reform of the physician payment system.  There was no agreement between the chambers to enter into negotiations on passing and paying for the bipartisan and bicameral repeal bill that was agreed to by their Medicare committees.  There was no admission by congressional leaders that they made a mistake by pushing through a patch.  Read ACP’s statement (this one’s for real) on the Senate vote.

There was no indication that Republicans are re-thinking their Obamacare repeal demands—if anything, they are doubling down, believing that it is their ticket to re-taking the Senate in the 2014 mid-terms.  No pledge to work with the President to improve it.  No new admissions of fault by President Obama and efforts to reach out to Congress to improve it.

Yet this part is true: Enrollment in the ACA marketplace plans as of last night’s “soft” open enrollment deadline was projected to near or exceed the original (pre-website debacle) target. Charles Gaba, who has had a remarkable record of accuracy in totaling up Obamacare enrollment, estimates that total ACA enrollment—qualified plans bought on the marketplace, qualified plans bought outside of the marketplace, Medicaid, and young adults on their parents’ plans—reached between 14.6 and 22.1 million people.  A new study estimates that nine and a half million of them were previously uninsured and fewer than a million of those whose health plans were “cancelled” still do not have coverage that meets the law’s requirements.  Yet the ACA’s critics are still in denial about the ACA enrollment surge, argues New Republic’s Jonathan Cohn.  

As I wrote a month ago in my Philadelphia Inquirer blog, caution  is in order in drawing conclusions too quickly on the Obamacare enrollment numbers.  Yet all indications are that enrollment will be on the high side, and more than 10 million previously uninsured will get covered in 2014, a potentially remarkable achievement given all of the obstacles (ones the administration imposed on itself, like the initial failed launch, and ones created by the unrelenting opposition to the law including the efforts in many states to impede enrollment).

In that sense, today is a banner day for U.S. health care, no foolin’.  Just think of how much better it could have been if only the rest of this blog were true, if Congress decided to get rid of the SGR rather than just patch it, and if Republicans and Democrats alike, Congress and the President, called a cease-fire on Obamacare repeal and worked instead to find bipartisan ways to improve it.  If only. 

Today’s question: what do you think about the developments over the past 24 hours on the SGR and the ACA (the true parts) and what might have been?

Friday, March 28, 2014

A (Not) Funny Thing Happened on the Way to the Quorum

Yesterday, the House of Representative voted for the 17th Medicare SGR patch over 11 years, an embarrassing record of futility in addressing real Medicare physician payment reform.  Even more embarrassing—and troubling to anyone who believes in the Founding Fathers’ vision of a good and transparent democracy—is the way that the House leadership orchestrated a secret voice vote to get the patch enacted when they knew that they didn’t have the votes.

Here is what happened.  The patch was opposed by ACP, AMA, the American College of Surgeons, and just about everyone else in organized medicine (More later on why).  Debate on the House floor started yesterday morning, and it quickly became apparent that the House leadership did not have the 2/3 voting super-majority needed to pass the patch (two-thirds was needed because the House had suspended the rules to allow for a quick vote).  Lacking a quorum, the House temporarily put off the issue.  Most members of the House expected to be called back later in the day, with a recorded vote for or against.

Instead, as Roll Call reports, “it was clear that a bill to avert a pay hike for doctors was short on support, so Republican leaders struck a closed-door agreement with Democrats to pass the bill by voice vote while members were not yet in the chamber, according to members and aides from both parties.”

The article continues, “The bipartisan power move to hold a voice vote allowed members to avoid a tough roll call, which would have forced them either to vote for a bill they do not support or allow doctors who treat Medicare patients to take a pay cut, incensing powerful outside interests. The tactic flies in the face of Speaker John A. Boehner’s pledge to be a transparent and rule-abiding Congress, members and aides said.  ‘I’ve seen a lot of dumb things, but I’ve never seen anything quite as comical as this,’ Rep. John D. Dingell, D-Mich., the longest serving member in the history of Congress, told CQ Roll Call.”

In my 35 years advocating for doctors in Washington, I also have never seen such a blatant and secret power-play, blessed by the leaders of both political parties, to win a vote they knew they had lost with zero individual member accountability.  But I don’t find it to be comical at all. 

As ACP President Molly Cooke said in a statement following the vote:

“Physicians and their patients need to know that today, by a voice vote—with no recorded votes and therefore no individual member accountability for their votes—the House of Representatives voted for the 17th short-term Medicare SGR patch over the past eleven years. By voting for the patch, the House failed to heed the unified call, of physicians who believe that now is the time for the House and Senate to reach agreement on the bipartisan reforms that were agreed to by the leaders of the Medicare committees of jurisdiction.”

“[This] would be the 17th patch enacted over 11 years to temporarily halt impending SGR cuts, at a budget cost of over $150 billion. Each time, physicians and patients were told that, this time, things will be different, that the temporary patch would give Congress the time it needs to achieve agreement on permanent reform. Why should physicians and patients believe that passing another patch now would result in permanent SGR repeal?

This one-year patch, if passed by the Senate, will likely give Congress the out it wants to push the entire issue of permanent SGR repeal and Medicare payment reform to the 114th Congress. The new Congress would then have to start over on crafting a permanent SGR repeal and Medicare payment reform bill that could clear the authorizing committees, pass both chambers, and be signed into law by the President—before this latest proposed patch expires on March 31, 2015. It is more probable that this would result in the enactment of patch #18 at an additional budget cost of tens of billions of taxpayers' dollars and further destabilization of Medicare.”

Notwithstanding the House vote, the College is not giving up on permanent SGR repeal.  In a letter sent today to all Senators, the College argued that the, “Senate can—and must—do better, by voting down the patch and passing the bicameral, bipartisan permanent SGR repeal legislation that was agreed to by the leadership of the authorizing committees.”  The Senate vote is expected to take place on Monday, April 1, at 5 p.m.  I encourage ACP members, and other readers of this blog, to call your Senators today and Monday to urge them to vote down the patch and pass real SGR repeal.  Click here for more information on how you can help.

I know that some of you may be worried that with a 24% SGR cut looming on Monday, that a patch may be the only way of stopping the cut. Consider this, though: every time that Congress has come up against the deadline for a scheduled cut, it has made the same old tired excuse, that a patch is the only option to stop it.  We have heard this from them 16 times over 11 years.  Each time they promise to do better, but they don’t and they won’t.  Congress has a choice other than to allow the 24% cut to take place or another patch, which is to pass the bipartisan, bicameral SGR repeal bill.

As we approach the Senate’s vote—which, ironically is supposed to take place the evening before April Fools Day—it would be good to remember the idiom, “Fool me once, shame on you; fool me twice, shame on me.”  Will we wake up on April 1, having been played the fool for the 17th time in 11 years?

Instead, it would be better to remember the classic rock anthem penned by The Who’s Pete Townsend and sung by Roger Daltrey, “We Won’t Be Fooled Again.”   Don’t be fooled into thinking that a patch is the only way to stop the 24% cut.  And remember, it is Congress, not organized medicine,  that’s  acting like the “Fools on the Hill” (Beatles).

Today’s questions: What do you think of the House’s secret vote to pass SGR patch #17?  What are you going to do to hold your House members and Senators accountable to enact permanent SGR repeal? 

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About the Author

Bob Doherty is Senior Vice President, American College of Physicians Government Affairs and Public Policy; Author of the ACP Advocate Blog

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