Caution Advised: Medicare's Physician-Payment Data Release (New Eng Jour Med)

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Caution Advised: Medicare's Physician-Payment Data Release

Patrick T. O'Gara, M.D.
May 28, 2014

On April 9, 2014, Health and Human Services Secretary Kathleen Sebelius announced the release of privacy-protected data concerning services provided to beneficiaries enrolled in the fee-for-service Medicare program in 2012; the services were provided by individual physicians and other health care professionals.1,2 The release occurred 10 months after federal district court judge Marcia Morales Howard of the Middle District of Florida vacated a 33-year ban on the publication of such information in a legal victory for Real Time Medical Data and Dow Jones.3 In her opinion, Morales Howard stated that the legal principles on which the previous injunction was based could no longer be sustained, citing case law that had narrowed the scope of the Privacy Act over the intervening three decades.3 Medical professional organizations had opposed lifting the ban, in part because of concerns that the loss of members' individual privacy rights could be harmful, especially if the data released were inaccurate and wrongfully created an aura of suspicious or inflated payments when none existed.

Much has transpired over the past several years with respect to public reporting of physician performance, hospital outcomes, and health systems' population management. To impede the release of Medicare data concerning physician and facility payments in the current environment would create a treacherous dynamic for providers and place them in a defensive posture that would be widely seen as a futile effort to maintain the status quo at the expense of enacting meaningful health care cost reforms. The implications of the data release are more nuanced than a simple accounting of payments, and caution should be exercised in interpreting and using these data, lest patients and the public misunderstand their applicability.

The newly released data set contains information on more than 880,000 individual health care providers in all 50 states and on 6000 procedures and services for which Medicare Part B paid $77 billion in 2012. Individual providers can be identified by name, unique provider identification number, geographic location, practitioner type, and Medicare participation status. The available information includes the number of Healthcare Common Procedure Coding System (HCPCS) codes submitted, the number of unique Medicare beneficiaries seen, the Medicare charges submitted, and the total dollar amounts allowed and paid to the provider.

The data are indeed unprecedented in scope, yet their limitations must be recognized if we are to place their meaning in the appropriate context. It is anticipated that fraud will be identified and prosecuted and that insights will be gained into any unfounded aspects of geographic variability in charge submission and payment — though these possibilities were not highlighted in Secretary Sebelius's press release about the data. Above all else, the data release should spark conversations between health care providers and patients about their shared responsibility for using resources in ways that maximize value.

http://www.nejm.org/doi/full/10.1056/NEJMp1405322?query=TOC