I expected to be like a kid in a candy shop this week when the federal Medicare program released, for the first time in nearly 40 years, data on what it pays to physicians, nurse practitioners, medical labs, surgery centers and ambulance services.
As all my readers know, I’m more than a little interested in what doctors and health systems are paid for their services.
But when I opened the databases, it was like biting into a piece of black licorice.
All that data—for 880,000 clinicians nationally—yielded precious few insights of any value. Perhaps that will change over time, as I and many others around the country try to make sense of it all.
But in the short term it was nearly impenetrable.
The Wall Street Journal constructed the handiest tool for looking at the numbers, which you can find here. But read some of the disclaimers the publication noted about the data, and then ask yourself if we can derive many meaningful insights from it.
Still, I did manage to glean several lessons from the numbers.
1. Medical labs, ambulance services and eye care are BIG businesses. As you can see below, seven of the 10 entities in Indianapolis that received the most money from Medicare in 2012 were clinical labs or ambulance companies. Among the top 20 recipients of Medicare payments, nine are opthamologists or surgery centers that perform cataract surgeries and other eye-related procedures.
1. AIT LABS, Clinical Laboratory: $13.8 million
2. MID AMERICA CLINICAL LABORATORIES LLC, Clinical Laboratory: $7.5 million
3. RURAL-METRO OF INDIANA LP, Ambulance Service: $7.2 million
4. DR. ANNE GREIST, Hematology/Oncology: $5.5 million
5. CARE AMBULANCE SERVICE LLC, Ambulance Service: $4.2 million
6. STRAND DIAGNOSTICS LLC, Clinical Laboratory: $4.1 million
7. DR. NIRAJ GUPTA, Hematology/Oncology: $3.4 million
8. AMERIPATH INDIANAPOLIS PC, Clinical Laboratory: $3.0 million
9. BELTWAY SURGERY CENTERS LLC, Eye Surgery Center: $3.0 million
10. AMBULANCE MANAGEMENT SERVICES LTD, Ambulance Service: $2.8 million
11. SURGERY CENTER OF ESI PC, Eye Surgery Center: $2.6 million
12. DR. STEPHEN SCHULTZ, Medical Oncology: $2.5 million
13. DR. RAJ MATURI, Ophthalmology: $2.1 million
14. DR. PAUL WALTON, Ophthalmology: $1.9 million
15. DR. THOMAS CIULLA, Ophthalmology: $1.7 million
16. EAST CAMPUS SURGERY CENTER LLC, Eye Surgery Center: $1.7 million
17. SURGICAL CARE CENTER INC., Eye Surgery Center: $1.7 million
18. ACTION AMBULANCE, Ambulance Service: $1.6 million
19. DR. RODNEY BUCHER, Ophthalmology: $1.6 million
20. I CARE CENTER, Eye Surgery Center: $1.6 million
2. Much of the money that Medicare pays to physicians actually goes to pharma companies, like Eli Lilly and Co. Out of the 100 highest-paid entities in Indianapolis, 38 of them are in one of three specialties—hematology/oncology, opthamology or rheumatology—in which a huge chunk of their revenue goes for drugs injected into patients. For the two Indianapolis physicians in the top 10 above, Dr. Anne Griest recorded 99 percent of her practice’s Medicare revenue for the injection of drugs, and Dr. Niraj Gupta recorded 89 percent of his practice for drug injections. Hematologists/oncologists do make profits on those drugs, but the margins on cancer drugs have decreased from more than 25 percent a decade ago to about 20 percent in 2010, and likely even less now. So most of those Medicare dollars to those specialists aren't staying with the physicians.
3. It’s important to remember these revenues are going to physician PRACTICES, not to individual physicians. In addition to covering the cost of supplies, these payments also have to cover the cost of the office space and, most significantly, the office staff. Consider that in Indiana, there are 12,280 physicians working in Indiana, but employment at physicians’ offices totals 48,700, according to the Bureau of Labor Statistics. That means each office-based physician has, on average, three additional people working to support him or her.
4. Health care finance is even more complicated than I thought. I already knew that the Current Procedure Terminology, or CPT codes, which form the basis of the Medicare reimbursement data just released, were nearly indecipherable. But these data do not allow independent observers to definitively attach revenue figures to individual clinicians, let alone do more sophisticated things like adjusting those payments for the level of a patient's sickness. One of my most astute readers pointed out that Medicare can and is attributing patients and their spending levels to specific clinicians now via some of its accountable care contracts. But that approach will need to become the norm before Medicare--and the public at large--will have a chance of managing health care spending. The famous business maxim is, “You can't manage what you can't measure." Well, for decades Medicare hasn't really been able to measure what it was spending. And private health insurers, who relied on the same coding system to make payments, weren't able to measure what they were spending either. Not at the level where change could occur. So is it any wonder health care spending has been out of control?
5. We have a long, long, LOOOONG way to go on price transparency in health care. Truth be told, I regarded the sealing of Medicare payments to doctors since a 1979 court injunction won by the American Medical Association to be a travesty of good government. I mean, we’re talking about $77 billion in annual government spending that has been hidden from the public at the request of the people receiving that money. That may be the biggest conflict of interest in history. So kudos to the Obama administration (and the lawsuit brought by the Wall Street Journal) for ending that sorry chapter. But the Obama administration is engaging in crazy talk when it says these data will help consumers.
“Currently, consumers have limited information about how physicians and other health care professionals practice medicine,” said Kathleen Sebelius, who is President Obama’s secretary of health and human services. “This data will help fill that gap by offering insight into the Medicare portion of a physician’s practice.”
The reality is that this data release, as monumental as it is, is only the first step. Huge amounts of work remain, not only by IT companies to make this payment information useful for consumers, but perhaps even more by regulators and providers to come up with more common-sensical ways to package and price their services.
“We know we have to do something about this, because it’s a sixth of our economy, the payment schemes don’t work, they’re antiquated, they don’t line up the risks and rewards right. We have to control this,” Ken Weixel, a Deloitte consultant told me this week in a conversation about new payment models in health care.
“This is a fascinating journey. I may be too old to see this full journey play out,” said Weixel, who is only 55.
As I said. We’ve got a long way to go.