Database: Some doctors getting millions from Medicare

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WASHINGTON (AP) — 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.
AP
picked the $3 million threshold because that was the figure used by the
Health and Human Services inspector general in an audit last year that
recommended Medicare automatically scrutinize total billings above a set
level. Medicare says it’s working on that recommendation.
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.
Rounding out the top five states were California with 38 doctors in the
top group, New Jersey with 27, Texas with 23, and New York with 18.
In
the $3 million-plus club, 151 ophthalmologists — eye specialists —
accounted for nearly $658 million in Medicare payments, leading other
disciplines. Cancer doctors rounded out the top four specialty groups,
accounting for a combined total of more than $477 million in payments.
Overall, Medicare paid individual physicians nearly $64 billion in 2012.
The median payment — the point at which half the amounts are higher and half are lower — was $30,265.
AP’s
analysis focused on individual physicians, excluding about 55,000
organizations that also appear in the database, such as ambulance
services. None of those entities was paid $3 million or more.
The
Medicare claims database is considered the richest trove of information
on doctors, surpassing what major insurance companies have in their
files. Although Medicare is financed by taxpayers, the data have been
off limits to the public for decades. Physician organizations went to
court to block its release, arguing it would amount to an invasion of
doctors’ privacy.
Employers, insurers, consumer groups and media
organizations pressed for release. Together with other sources of
information, they argued that the data could help guide patients to
doctors who provide quality, cost-effective care. A federal judge last
year lifted the main legal obstacle to release, and the Obama
administration recently informed the American Medical Association it
would open up the claims data.
"It will allow us to start putting
the pieces together," said Dianne Munevar, a top researcher at the
health care data firm Avalare Health. "That is the basis of what payment
delivery reform is about."
Doctors’ decision-making patterns are
of intense interest to researchers who study what drives the nation’s
$2.8-trillion-a-year health care system. Within the system, physicians
act as the main representatives of patients, and their decisions about
how to treat determine spending.
The American Medical Association,
which has long opposed release of the Medicare database, is warning it
will do more harm than good.
The AMA says the files may contain
inaccurate information. And even if the payment amounts are correct, the
AMA says they do not provide meaningful insights into the quality of
care.
"We believe that the broad data dump … has significant
shortcomings regarding the accuracy and value of the medical services
rendered by physicians," AMA president Ardis Dee Hoven said. "Releasing
the data without context will likely lead to inaccuracies,
misinterpretations, false conclusions and other unintended
consequences."
The AMA had asked the government to allow individual doctors to review their information prior to its
release.
Over
time, as researchers learn to mine the Medicare data, it could change
the way medicine is practiced in the U.S. Doctor ratings, often based on
the opinions of other physicians, would be driven by hard data, like
statistics on baseball players. Consumers could become better educated
about the doctors in their communities.
For example, if your
father is about to undergo heart bypass, you could find out how many
operations his surgeon has done in the last year.
Research shows that
for many procedures, patients are better off going to a surgeon who
performs them frequently.
The data could also be used to spot
fraud, such as doctors billing for seeing more patients in a day than
their office could reasonably be expected to care for.
Medical
practice would have to change to accommodate big data. Acting as
intermediaries for employers and government programs, insurers could use
the Medicare numbers to demand that low-performing doctors measure up.
If the data indicated a particular doctor’s diabetic patients were
having unusually high rates of complications, that doctor might face
questions.
Such oversight would probably accelerate trends toward
large medical groups and doctors working as employees instead of in
small practices.
Melgen, the top-paid physician in 2012, has
already come under scrutiny. In addition to allowing the use of his jet,
the eye specialist was the top political donor for Menendez as the New
Jersey Democrat sought re-election to the Senate that year.
Menendez’s
relationship with Melgen prompted Senate Ethics and Justice Department
investigations. Menendez reimbursed Melgen more than $70,000 for plane
trips.
The issue exploded in late January 2013, after the FBI
conducted a search of Melgen’s West Palm Beach offices. Agents carted
away evidence, but law enforcement officials have refused to say why.
Authorities declined to comment on the open investigation.
___
Associated Press writer Kelli Kennedy in Miami contributed to this report.
Copyright 2014 The Associated Press. All rights
reserved. This material may not be published, broadcast, rewritten or
redistributed.

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