Some of the figures were astounding (astronomical). I am sure that payers, the public, and even some orthopaedists are contemptuous of those on the lists, particularly those at the top. I know I was, especially when all that appeared was a dollar amount with no explanation. I guess my emotion was jealousy: “Where’s mine? I work just as hard for my patients as they do.”

AAOS Now

Published 7/1/2014
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S. Terry Canale, MD

Avoid Contempt Prior to Investigation

Recently, several lists have been posted on the Internet and in print concerning monies paid to physicians, including orthopaedists. The Centers for Medicare & Medicaid Services (CMS) posted total Medicare payments, Medscape posted its 2014 “Physician Compensation Report,” medical device companies have been posting payments for several years, and “Sunshine Act” payments will soon be posted as well.

The amount of compensation paid to different specialists is the most innocuous list. Orthopaedists reported the highest earnings, with an average income of $413,000; cardiologists were a distant second with an average income of $351,000. I don’t get heart palpitations from my atrial fibrillation over this—orthopaedics is a popular specialty. The musculoskeletal system seems to break down more often as it gets older (much like an old car), so more patients need our help. More afflictions = more patients = more income. And that should be the end of the story.

Not quite. You had to go to the small print to discover that “Earnings are for full-time work only. They include salary, bonus, and profit-sharing contributions. For partners, these are earnings after taxes and deductible business expenses but before income tax.” And you never did find out where and how hard these doctors worked or how large their practices were. That leaves the door open for the public, policymakers, and even other physicians to question the numbers and point fingers at orthopaedists without knowing the full story.

Then there was the CMS list of payments received by physicians and other providers for treating Medicare beneficiaries. When I heard the list was coming out, I was anxious and did have sweaty palms, thinking that my equation (older patients = more afflictions = more payments) would reflect poorly in the eyes of public opinion. But I was pleasantly surprised to learn that orthopaedics was not in the top 15 and was barely just ahead of nurse practitioners.

Several days later I read an article in my hometown paper, The Commercial Appeal, about how “Reimbursement tops $1,000,000 for 16 city doctors.” Now I knew that this was one list I didn’t want to be on. Six of the 16 were ophthalmologists and none were orthopaedists. I guess more older people have more “broken retinas” than “broken hips,” but not even a simple explanation was given (other than all received more than $1,000,000).

One of the ophthalmologists had a rebuttal printed the next day, but it was way in the back of the paper and mentioned that one provider number was used for all the doctors in the office. That started me thinking about this. Why am I or any other physician getting sweaty palms over these lists? This is not Medicare fraud. This is the real deal. If I see a lot of Medicare patients, I should be compensated appropriately under Medicare. CMS should be happy that physicians are willing to see Medicare patients. I shouldn’t feel guilty about it.

When CMS lists Medicare payments to physicians and media outlets report on those who receive the most money, like it or not, the implication is that the physicians or specialists are “ripping off” the government. Without doing some investigation, people could assume that the Top 10 (or more) might be involved in some sort of Medicare fraud. As a result, there is “contempt prior to investigation” for those high on the list who receive substantial compensation.

But let’s investigate for a moment and consider the following:

  • Some physicians won’t see Medicare patients because their practices are filled with patients who have private (commercial) insurance that pays better than Medicare.
  • Some physicians will see only a “set” number of Medicare patients and some will see none.
  • Some specialists, such as those in sports medicine or pediatrics, don’t see older patients.
  • Some practices (offices) use one doctor’s identification code to bill on behalf of all the doctors (and perhaps all the other healthcare providers as well) in the practice.
  • When it comes to fraud, CMS and “whistle-blowers” have looked hard at the “leader board.”

For these reasons and more, different specialties and physicians are or are not on the “Top 10 Highest Paid” list of providers, which isn’t bad, wrong, or unethical.

As I mentioned earlier, orthopaedics is the highest income-producing medical specialty and is way down the list in income received from Medicare. I won’t even go there, except to say that if you think about that for a minute, you will probably come to the same conclusion I did!

I think the government, CMS, and whoever should be more sensitive about the lists they put on their websites. I think it is unprofessional and unjust (unfair) just to throw something out there (like feathers from a damaged pillow or gossip) without any explanation and allow the public to draw false conclusions because of a lack of investigation. This is reminiscent of the time when the Department of Justice (back when New Jersey Governor Chris Christie was a U.S. District Attorney) made the orthopaedic device companies post the names of orthopaedists and the amount of money paid to each. The AAOS argued unsuccessfully that there should be an explanation with the list, indicating that the payments were for royalties, consultations, lectures, or whatever. After all, there is a considerable difference between a paid consultant and an inventor who receives royalties.

On the other hand, Sen. Orrin Hatch of Utah, the senior Republican on the Senate Finance Committee, which oversees Medicare, argues that this type of reporting by CMS and others stimulates transparency and, he hopes, decreases some of the abuse in the Medicare system. I tend to agree, but if this is the intent, more and better data would make the system more transparent than it is currently. Now it is almost accusatory without providing enough facts or explanation for readers to form an objective opinion.

Organized medicine, including the AAOS, while supporting the concept of transparency, has argued that the release of private financial information about healthcare practitioners, physicians, practices, and hospitals should be done responsibly and that physicians must have an opportunity to correct inaccuracies.

Soon, in September 2014, the new “sunshine provisions” of the Affordable Care Act will release financial information from 2013 (August through December) about relationships between doctors and hospitals and device companies and group purchasing organizations. Each individual physician, hospital, and other health providers on the list, starting June 2, 2014, has the opportunity to register to review their own data prior to the public release of the information. If necessary, during the period June to September, this information can be disputed and corrected prior to public posting. (See this month’s cover story “Foggy Forecast for Sunshine Act” and “Don’t Get Burned by Sunshine Data” in last month’s issue of AAOS Now.)

If information on physician payments and performance is going to continue to be released, organized medicine should continue its efforts to ensure that the data are accurate, complete, and fully explained so that the public can “avoid contempt prior to investigation.”

S. Terry Canale, MD, is editor-in-chief of AAOS Now. He can be reached at aaoscomm@aaos.org