- What information was released?
- How was this payment information released?
- Why was this information released at this time?
- How does this recent change in policy relate to other CMS efforts regarding healthcare transparency?
- How does the release of this physician payment information relate to American College of Physicians (ACP) policy regarding healthcare transparency?
- What is the most appropriate use for this released payment data?
- What are some common problems that have occurred as a result of how CMS chose to release this information?
- What actions has ACP taken and plans to take in response to problems related to this data release?
1. What information was released?
On April 9, 2014 CMS released to the public finalized 2012 fee-for-service (FFS) Medicare Physician Fee Schedule (Part B) payment information linked to the National Provider Identifier (NPI) of more than 880,000 health care professionals in all 50 states who collectively received $77 billion in payments. This is the first time specific information regarding Medicare payments provided to identifiable physicians and other healthcare professionals has been made public. CMS made public the following information for each paid-for service ---- as identified by its Healthcare Common Procedure Coding System (HCPCS) code:
- Number of times service was provided
- Average submitted charges
- Average allowed amount
- Average Medicare payment
- Number of unique beneficiaries treated
No identifiable patient data was released and information was not provided for physicians and other healthcare professionals who submitted claims for fewer than 11 Medicare beneficiaries for that year.
2. How was this payment information released?
Data was released as a downloadable raw data file set available at https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Physician-and-Other-Supplier.html.
From this site, data can be downloaded as a:
- Tab delimited file format requiring importation into database or statistical software, or,
- Microsoft Excel format
The CMS site includes a detailed description of how the released data is defined, how it was developed and includes the following brief cautionary statement regarding the limitations of this information:
"… the dataset has a number of limitations. Of particular importance is the fact that the data may not be representative of a physician's entire practice as it only includes information on Medicare fee-for-service beneficiaries. In addition, the data are not intended to indicate the quality of care provided and are not risk-adjusted to account for differences in underlying severity of disease of patient populations..."
Additional user-friendly sources for this data have been developed by the New York Times (http://www.nytimes.com/interactive/2014/04/09/health/medicare-doctor-database.html), and Washington Post (http://www.washingtonpost.com/wp-srv/special/national/medicare-doctors-database/).
On April 24, 2014, CMS released a more user-friendly data source at https://data.cms.gov/use-agreement/data-limitations/provider-explorer.
3. Why was this information released at this time?
CMS had been banned from fulfilling requests through the Freedom of Information Act (FOIA) for identifiable Medicare provider payment information as a result of a 1979 court injunction stemming from a lawsuit that the American Medical Association and the Florida Medical Association filed based upon invasion of physician privacy concerns. This injunction was lifted by a federal judge in May, 2013 and CMS announced in a January 2014 Federal Register notice a required change in policy to release such information through FOIA processes as a result this judiciary action.
4. How does this recent change in policy relate to other CMS efforts regarding healthcare transparency?
This decision is consistent with a number of recent actions by HHS/CMS in support of greater healthcare data transparency to improve healthcare quality, efficiency and safety. These actions include:
- The release, beginning in 2010, of previously unpublished statistics available at www.healthdata.gov ranging from statistics on Medicare spending, utilization, and quality at the state, hospital referral region, and county level, to detailed information on the quality performance of hospitals, nursing homes, and other providers.
- The release in May 2013 of the average charges for the 100 most common inpatient services at more than 3,000 hospitals nationwide http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Inpatient.html.
- The release in June 2013 of average charges for 30 selected outpatient procedures http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Outpatient.html.
- The recent implementation of the Open Payments (Sunshine Act) provision of the Affordable Care Act in which financial relationships between industry and physicians/teaching hospitals will be publically reported beginning September, 2014. http://www.cms.gov/Regulations-and-Guidance/Legislation/National-Physician-payment-Transparency-Program/index.html
5. How does the release of this physician payment information relate to American College of Physicians (ACP) policy regarding healthcare transparency?
ACP has extensive policy in support of transparency throughout the healthcare system. This policy is most clearly articulated in the 2010 policy paper "Healthcare Transparency --- Focus on Price and Clinical Performance Information' available at http://www.acponline.org/advocacy/current_policy_papers/transparency.pdf. The policy paper reflects the College's general support for the concept of healthcare transparency contingent on the reported information meeting a number of important criteria including the information being:
- reliable and valid
- transparent in its development
- open to prior review and appeal by the physicians and other healthcare professionals
- minimally burdensome to the reporting physician and other healthcare professionals
- comprehensible and useful to its intended audience including a clear statement of its limitations
Based on this policy, while the College supports the public release of this information, it has concerns regarding the process and format of this release. More specifically, the College would have preferred that:
- Physicians and other healthcare professionals had an opportunity to review the data for accuracy prior to its public release.
- The data was released in a more user-friendly format.
- The data was coupled with clear information regarding its appropriate use and its limitations.
6. What is the most appropriate use for this released payment data?
Despite unfortunate and ill-informed comments in a related CMS press release and articles found in mass-media sources, the consensus of the healthcare policy community is that this information in its present form is of little or no value to patients/consumers. More relevant uses, generally requiring coupling with other data and analytic software, include:
- Use by researchers to learn more about how our current healthcare system works e.g. to answer such questions as why there are significant variances in service utilization throughout the country.
- Use by insurance companies and other payers to develop high value networks and utilization benchmarks.
- Use by CMS, other agencies and related contractors to screen for fraud and abuse.
7. What are some common problems that have occurred as a result of how CMS chose to release this information?
Problems reported to the College by its members and others include:
- The reporting of inaccurate data
- The following misinterpretations due to the limited contextual information provided by CMS:
- Payment to multiple physicians and other healthcare professionals reported under a group NPI viewed as being paid to one physician or healthcare professional.
- Payment that included reimbursement for expensive physician- purchased medications and/or medical equipment viewed solely as payment for the service.
- The perception that reported large payments resulted solely from unnecessary or inappropriate utilization ---- without taking into account such interactive factors as patient-mix, and the issues indicated above.
8. What actions has ACP taken and plans to take in response to problems related to this data release?
The College, both individually and in collaboration with other medical societies, has had several conversations with CMS to address problems with the current data release, and to minimize problems with releases in the future. CMS has already agreed to develop a process to correct any inaccurate data reported in this current release. They have also agreed to take into consideration in future releases our call for increased information about what the information means and its limitations ---- to limit the likelihood of misinterpretation.
ACP also, on its own and with other medical societies, plans to develop information for its members and the public that should allow for better understanding of the data. This FAQ document is an example of this effort.