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In balancing physician privacy and cost transparency, CMS determined that the data release would serve “a significant public interest.”
Courtesy of Thinkstock

AAOS Now

Published 5/1/2014
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Elizabeth Fassbender

CMS Releases Payment Data on Physicians

Comparatively, orthopaedics has good showing

The federal push for transparency regarding payments to physicians took another step forward when, on April 9, 2014, the Centers for Medicare & Medicaid Services (CMS) released data on Medicare payments for services provided in 2012 by approximately 880,000 physicians. These data include the number and type of services provided by each physician, average allowed payment, and the average Medicare payment paid to physicians.

The decision to release the data followed a court ruling in May 2013 that lifted a 33-year injunction prohibiting the Department of Health and Human Services from releasing any payment information that could be used to identify individual physicians. Since the court ruling, CMS has received multiple requests to release the data under the Freedom of Information Act. Although CMS initially said it would consider requests for the data on a “case-by-case” basis, it later determined “that the public’s interest outweighs the privacy interests” for the data released.

According to Jonathan Blum, CMS principal deputy administrator, the “release of physician-identifiable payment information will serve a significant public interest by increasing transparency of Medicare payments to physicians, which are governed by statutory requirements, and shed light on Medicare fraud, waste, and abuse.”

AAOS response
Frederick M. Azar, MD,
president of the American Association of Orthopaedic Surgeons (AAOS), released a statement saying that the AAOS “supports increased transparency and is committed to improving the quality of care of all patients,” but is concerned that because these data are raw and not risk-adjusted, they may be misleading to the average patient.

“The data do not account for factors such as the age and overall health of patients seen, their degree of medical comorbidities, and the severity of the conditions being treated, which makes it challenging to compare or assess physicians’ cost for similarly coded procedures and treatments,” Dr. Azar stated.

Dr. Azar also noted that the data may not reflect actual revenue received by physicians. “Charges often represent an amount determined by hospitals to be appropriate, and actual revenue received from Medicare is frequently much lower than the amount charged,” he explained.

Another issue is accuracy of the data. Dr. Azar noted that physicians had no opportunity to review the information before its release. “To ensure accuracy, physicians should have the opportunity to preview this kind of information before its release and to challenge or audit the data being published,” he said.

Data sets
The data are organized by National Provider Identifier (NPI) number and contain data by Healthcare Common Procedure Coding System (HCPCS) code and site of service (facility or nonfacility setting). Cost data for procedures include the number and type of services provided by each physician, average allowed payment, and the average Medicare payment paid to doctors in 2012. The data do not include personally identifiable patient information about procedures performed on fewer than 11 patients. Data that have not been released by CMS, however, are utilization of the Medicare Advantage and Medicare Part D prescription drug programs.

Early analyses
Although researchers and others will continue to examine the data over the coming weeks, early reports focused on the following items of note:

  • Approximately 2 percent of doctors accounted for about $15 billion, or about a quarter of total Medicare spending in 2012.
  • Ophthalmologists and oncologists are among the top-billing doctors; according to the New York Times, orthopaedic surgery ranked 13th.
  • Almost 4,000 physicians were paid more than $1 million each in 2012 by Medicare, and the average payment per physician was $77,000 for that year.

In addition to the data released on Medicare payments to physicians, CMS released similar data on payments to hospitals for the 100 most frequently billed discharges by Diagnostic Related Group. Similar to the data on payments to physicians, these data contain information on what a hospital charged as well as the payments actually received from Medicare. CMS has not indicated whether or when additional data may be released.

Elizabeth Fassbender is the communications specialist in the AAOS office of government relations.

Additional Information