Eyes on the Medicare data dump: Cautions and cautionary tales

On Wednesday came the government release, finally, of Big Data on Medicare payments to medical practitioners for 2012. The beginning, one hopes, of release of many more years of data in aid of trend-spotting. Also, surely, some reining in of the grossest of these payments. Surely?

The data will keep science and medical writers busy for some time. You can find news about Wednesday’s massive Medicare data dump everywhere, but here’s Jordan Rau’s compact opener for Kaiser Health News: “The federal government published data tracing the $77 billion that Medicare paid to physicians, drug testing companies and other medical practitioners throughout 2012, and what services they were being reimbursed for. The data cover 888,000 different practitioners. More than 6,000 procedures are included, and the full database is so large that it requires statistical software to analyze it.”

At a Business Day post by Andrew Pollack and Reed Abelson there’s a link to the New York Times‘s interactive graphic permitting easy-peasy lookups of what individual practitioners got from Medicare by locale. The two docs who saved me from major surgery 3 years ago, and probably also saved my life, are not listed because they are not in private practice; they work in academic institutions and are salaried. Handsomely, I hope.

Big data can sometimes be misleading

Most writers focused, not surprisingly, on the most eye-popping payments. Heaven knows there were great riches to choose from. But many writers also dove a little deeper. At Wonkblog, Jason Millman listed the Medicare Top Ten multi-millionaires, but also explored what expenses they claimed. For 7 of the 10, a huge proportion of their reimbursements went for drugs administered on site. So I guess it’s not the poor beleaguered docs who are soaking the taxpayers after all. It’s the pharmas.

Rising Cost of Healthcare
A Business Day post by Denise Grady and Sheri Fink shows how the data can mislead. One example: a family medicine physician at the University of Michigan Health Services got $7.58 million in 2012 for more than 207,000 patients. Unbelievable, right?

Except, as it turns out, the doc directs a Medicare project involving 1600 primary care physicians, and the payments to them go through her office. So I did the math, which works out to well under $5K for each doc, with an average of 130 patients each for the year. At $36.62 per patient. Looks as if the University of Michigan Health Services, where I was once or twice a patient back in the last century, is a model of efficient and reasonably priced–cheap, in fact–medicine. Maybe I’ll go back to grad school after all.

At Medpage Today, John Gever consulted docs, who were mostly unhappy with the data release. Their comments ranged from “IT’S NONE OF YOUR BUSINESS WHAT I’M GETTING FOR MY SERVICES,” not really a reasonable reaction to expenditure of public money, to the perfectly sane worry that people would assume the figures reflect what the doc takes home, not gross receipts that must cover staff, overhead, and much else.

Charles Ornstein, a longtime journalist now at ProPublica, laid out several cautions on interpreting the data at Covering Health, the blog of the Association of Health Care Journalists. If a practitioner treats only Medicare patients, he points out, the payment may well be larger than one going to a doc who treats privately insured patients too. Or the doctor may provide services–cancer care, for instance–that are reimbursed at a high rate. Ornstein cautions, “Of course, there may be other reasons that raise questions of fraud, but don’t just assume that because a number is large, a doctor has done something wrong.”

Not seeing eye to eye

On the other hand, there are all those handsomely paid opthalmologists. The 17,000 eye docs, less than .02% of the total number reimbursed, took in 7% of Medicare reimbursements. $5.6 billion, $330,000 per.  Max Ehrenfreund sees opthalmologists through a glass darkly at Wonkblog.

The Pollack-Abelson Business Day post mentioned above features a
defense of opthalmologists. Sort of. It includes a splendid map showing the locales of those most reimbursed.

A billion of the $5.6 opthalmological billion goes for the macular degeneration drug Lucentis. $2000 per injection, often once a month. Most of which, the docs say, they pay to Genentech, Lucentis’s maker. Maybe so, but the docs profit handsomely. The post explains why. Among the reasons, big rebates from Genentech. And I love the tale of the docs who accumulate zillions of frequent-flyer miles by putting Lucentis orders on miles-bearing credit cards.

A Lucentis alternative for macular degeneration, also by Genentech, is off-label use of the cancer drug Aventis. It costs $50 per treatment. Even if Lucentis is better than Aventis–and none of the docs quoted in the post argue that it is–can it possibly be 40 times better?

Keeping my eye on opthalmologists

One does wonder if there’s something about opthalmologists. Here is a personal anecdote, so it’s not data. Well, two anecdotes, but still not data. I lost the sight in my right eye permanently when I was 35. Long story, so let’s move right along to many years later. In the last 10 years, two different opthalmologists in two different parts of the country have urged me to have surgery, offering hope of improving vision in that eye.

medicare card female

For a number of reasons, not least my own not-unskilled research, I know that the surgery they were proposing would not restore vision in that eye, not even partially. When I pointed this out, each of the docs shrugged, conceded that he couldn’t guarantee a satisfactory result, but urged me to consider surgery (by him) anyway. Cheeky. Breathtaking, actually.

Please also note that in each case surgery was a suggestion out of the blue from the doc. I had not come to his office seeking therapy for my bad eye; I was there for other reasons.  A driver’s license, in one case. These were sales jobs, pure and simple, urging a procedure that the salesmen knew to be useless.

Too bad for their bottom lines that the potential customer knew it too. But in this case the potential customer was unusually prepared. Her career was based on looking skeptically at medicine, and she had researched the topic herself. What about the 99.9999etc% of customers who lack that specialized armor? Who rely on physicians to give them medical advice untainted by self-interest?

If this had happened only once I would probably, um, have turned a blind eye; I happen to have one handy. But it has occurred two times, unprompted. That hints at a trend. I wonder what would happen if, as an experiment, I trundled from eye doc to eye doc? I have a hunch that at least some would suggest surgery. I very much hope that most would not. But when I think about Lucentis vs. Aventis, and frequent-flier miles. . . Maybe there is something about opthalmologists.

Medicare data summaries galore

Kaiser Health News is all over the story about the Medicare data release, with summaries of commentary from many mainstream media sources and links to the originals, plus several of its own posts too.

Wonkblog has summaries of commentaries (and links) too.

medicare parts

Department of blind outrage

Release of the Medicare payment data provides justifiable opportunities for dudgeon, none higher than that of Knight Science Journalism Tracker Paul Raeburn. The reason we did not have the data years ago, he explains, is that the American Medical Association has been fighting (successfully) to keep this use of taxpayer money out of the public eye since 1979. As Raeburn points out, the shock generated by these numbers makes it clear why the AMA was so dedicated to keeping it hidden.

He links to a number of pieces explaining the data, but observes, “I’m surprised that the role of the AMA in keeping the data secret hasn’t yet been hit hard in these publications. It’s stunning that it was able to keep this information secret for 35 years; I’m waiting for the legal story that examines how that happened.”

I second that, and how. I’d adore to see Linda Greenhouse turned loose on this story. It was a Federal court decision that freed the Medicare data, though, and I think she only does the Supremes.

One lovely tidbit: It was, believe it or not, the Wall Street Journal that pursued disclosure of the data down the years and won this legal victory for transparency, capitalism be damned. A number of sources have chided the New York Times for not giving the WSJ credit for its doggedness. The complaints were chronicled by Times Public Editor Margaret Sullivan.  She joined in, biting the hand that feeds her, but also slyly noted that the Washington Post, USA Today, and the Associated Press didn’t mention the Journal‘s role either.

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