Agency releases Medicare payments data

April 10--Medicare payments made to individual physicians topped $75 billion in 2012, with sometimes wide variation in payments by geographic region and specialty. By comparison, payments to Pittsburgh-area physicians "appear to be very reasonable," said one local expert.

The Centers for Medicare and Medicaid Services, or CMS, made the unprecedented data release Wednesday "to make the Medicare program and broader health care programs much more transparent to researchers and the broader public," said Jonathan Blum, principal deputy administrator at the agency.

"We know that there is waste in the system. We know that there is fraud in the system," he said. "We want the public to help identify spending that doesn't make sense, that appears to be wasteful, that appears to be fraudulent."

Because Medicare sets the rates it pays physicians, the data released Wednesday will not necessarily help individual consumers learn what they will pay for medical services. For example, it does not include commercial insurance data or factor variables such as facility fees that a hospital may charge.

The American Medical Association questioned the overall value of the massive data dump, citing a lack of context in its release.

However, the 10 million lines of data released Wednesday will be a treasure trove for researchers, as well as members of the public who are curious about how their physician stacks up against others.

The data can be viewed online at www.cms.gov by clicking on the link under the "CMS News" heading.

Immediate attention, of course, went to those providers collecting the largest payments from Medicare.

An early analysis by The Associated Press found that 344 physicians of the 825,000 in the Medicare database took in at least $3 million apiece, topped by Florida ophthalmologist Salomon Melgen, who collected $20.8 million in 2012. AP reported that Dr. Melgen's attorney attributed his high billing numbers to high drug costs and said his client had followed Medicare billing rules.

Three Pittsburgh physicians received more than $1 million in payments from Medicare, including Oakland interventional nephrologist Sandeep Sharma, who took in $1.87 million. Interventional nephrology involves helping patients with kidney disease who are having difficulty with their dialysis treatments.

Dr. Sharma said Wednesday that he is one of only three interventional nephrologists in the region and the only solo practitioner. While not taking issue with the amount reported by CMS, Dr. Sharma expressed concern about how the information was presented.

"My worry is how the numbers will be interpreted by the general public with no context," he said. "They are just releasing a number, and that doesn't mean that number is what I took home because I have overhead [costs]."

His office includes six staff members and there are equipment costs to consider, he said. Those expenses must be met even as Medicare has been cutting reimbursement payments.

Also, because Dr. Sharma performs his procedures in his clinical offices, he said, Medicare bundles the professional and technical fee payments that would be classified separately if the procedures were done in a hospital.

Two other Pittsburgh physicians had more than $1 million in Medicare payments for 2012 -- ophthalmologists Marc Hoffman and Edward Sorr, who practice at five different Tri-State locations with Everett & Hurite Ophthalmic Association.

In a national teleconference media briefing Wednesday, CMS's Mr. Blum noted that certain specialties such as oncology and ophthalmology tend to use higher-price drugs. And while high billing numbers may draw the agency's attention, he added, the large payments may also indicate a provider's particular expertise at handling complex medical problems.

"Overall, it appears that Medicare payments to Pittsburgh physicians appear to be very reasonable," said Stephen Foreman, associate professor of economics and health administration at Robert Morris University. "Moreover, there are very few physicians here who get very large payments."

Ultimately, CMS may be more interested in looking at why payments for the same procedure vary from one area of the country to another. The AP analysis, for example, found that about 1 in 4 of the top-paid physicians practice in Florida.

"We want the public to help us with this effort," Mr. Blum said.

There had been some question about whether the data would be released Wednesday, as CMS had anticipated that the AMA might take legal action to block its release.

In a statement on its website, AMA president Ardis Dee Hoven said the data dump "has significant shortcomings regarding the accuracy and value of the medical services rendered by physicians," since it does not include information on quality, value and outcomes. "The AMA is disappointed that CMS did not include reasonable safeguards that would help the public understand the limitations of this data."

But Mr. Blum said patients and taxpayers have a right to know where and how taxpayer-funded Medicare money is spent. He said, "Various legal proceedings prevented this agency from releasing" the information earlier.

"It should have been out long ago."

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Steve Twedt: stwedt@post-gazette.com or 412-263-1963.

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