Data may help curb health care cost

• Newly released Medicare data covers claims for more than 825%2C000 doctors across the U.S.
• Locally%2C 114 individual doctors billed %241 million or more to Medicare in 2012.
• Experts caution that the data has critical limitations%2C including no Medicare Advantage claims.

Health care experts have officially begun a long-awaited dive into newly released data showing how much doctors charge and receive for treating Medicare patients.

Medicare is among the largest buyers of health care in America. So what the program pays doctors can offer clues about what private insurers pay, such as giving insight into less-than-transparent costs for specific medical treatments.

With more than 20 percent of insured Americans now in high-deductible plans that encourage beneficiaries to shop around, any information about costs can be helpful.

Finally, the data also gives taxpayers some idea what the government is buying with the billions it spends on health care.

The release last week of the claims data for more than 825,000 doctors and other medical care providers marks a "watershed moment" for health care in the U.S., said Craig Brammer, CEO of Norwood-based Health Collaborative.

"This has been 30-years-plus in the making, but it's certainly not the end of the story," said Brammer. "We are on a journey of transparency, and this is just one stop."

The Medicare database has been kept from the public eye for decades, blocked in courts by physician groups who argued the data could cause public misunderstanding of health care prices, costs and reimbursement rates.

But journalists, insurers, employers and consumer groups calling for more transparent costs across the country's $2.8 trillion health care system have continued to press for the files to be opened.

Earlier this month, the Obama administration announced it would do so. But the data has lots of limitations.

First, the Centers for Medicare and Medicaid Services (CMS) released billings only for 2012.

The data set excludes payments for beneficiaries in Medicare Advantage plans, which are offered through private insurers. Those plans account for roughly 30 percent of seniors eligible for Medicare nationally. But Medicare Advantage plans are more popular locally, with just over 43 percent of beneficiaries covered.

Also left out of the new data are payments to doctors who treated 10 or fewer Medicare patients and billed more than $150,000 in charges. The data also doesn't account for outcomes or the condition of the patients before the procedure.

"The most critical limitation is that the data doesn't provide context in terms of what type of patients these physicians were seeing or what their costs were," said Brammer, whose nonprofit created the website www.yourhealthmatters.org to allow local consumers to compare quality ratings of primary care providers and hospitals across the region.

"In every medical specialty, there are costs associated with the care," he said. "The new data just shows us the amounts paid out, but not the profits."

The data includes $77 billion in Medicare payments from 2012 for Medicare Part B, which covers payments to doctors and providers for services at hospitals, offices and other facilities.

The program also pays for medical supplies and services including lab tests, X-rays, physical therapy and ambulance services.

The data gives providers' names, specialties, addresses, billings, average price per beneficiary and number of beneficiaries. To protect their privacy, there is no information about patients.

Charges from and payments to 543 local providers, including doctors, group practices and ambulance services, are included in the national database.

An Enquirer analysis of the data shows that the median claim submitted to Medicare for all individual doctors and providers locally was $597,000. The median paid by Medicare was $222,000, for a reimbursement rate of 40.5 percent.

The data also shows:

• 114 individual doctors locally billed $1 million or more.

• 8 individual doctors were reimbursed $1 million or more.

• 36 providers billed $1 million or more.

• 13 providers were reimbursed $1 million or more.

Nationally, seven physicians in the U.S. received more than $10 million in reimbursements. They range from ophthalmologists who submitted claims for specialized, high-cost drug treatments to pathologists who billed the program for thousands of clinical tests performed by their labs, according to a report by USA TODAY.

Data could curb fraud,improve quality long term

The data release comes as the government is trying to refashion the way America's health care system is financed. Earlier this year Medicare invited advice on how it should devise new ways of paying specialists to replace the current system, in which doctors are paid a set fee for each visit or procedure. The goal of these approaches is to remove the financial incentive for practitioners to do more services.

Dr. Kavita Patel, a former White House health care expert and a researcher at the Brookings Institution, a Washington-based think tank, said the Obama administration's timing was not coincidental. "They are building the case for doing targeted specialty payment models," she said.

Under the authority of the federal health care law, the administration has already launched experimental programs aimed mostly at hospitals and large medical groups, including some in the Cincinnati region. There are hundreds of trial efforts under way to pay medical practitioners a set fee to treat a defined ailment, such as replacing a knee, with the fee covering all aspects of the care from before the operation through the recovery and any setbacks.

Meanwhile, CMS said last week that it plans to take a closer look at doctors whose payments exceed certain levels, but those thresholds aren't being revealed to prevent tipping off those trying to take advantage of the $600 billion Medicare system for the elderly and disabled.

"We know there is waste in the system, we know there is fraud in the system," said John Blum, deputy administrator at CMS. "We want the public to help identify spending that doesn't make sense."

Over time, access to the Medicare data and that of private insurers and providers can change the way American medicine is practiced, said Brammer.

"The crucial next step is to be able to blend the data for all those who pay for health care – the government, employers and commercial insurers," said Brammer. When that happens, "you really get a clear view of not just costs but quality of health care."

The Associated Press and Kaiser

Health News contributed. ■