Skip to main content

Advanced Search

Advanced Search

Current Filters

Filter your query

Publication Types



Newsletter Article


Release of Doctor Billing Data May Help Insurers, Trial Lawyers

By John Reichard and Adriel Bettelheim

April 9, 2014 -- The Obama administration is portraying the recent release of a trove of Medicare physician payment data as an exercise in transparency that will help taxpayers see how their money is being spent and encourage consumers and researchers to identify excessive billings.

The biggest beneficiaries, however, may be health insurers and hospitals eager to reduce overuse of certain costly treatments, and trial lawyers looking for patients who have been readmitted to hospitals or who have had repeat procedures for the same medical problem.

Health policy experts and former government officials say the release of 2012 billing data for $77 billion of claims under Medicare's Part B fee-for-service program is part of a longstanding pattern in which the government releases Medicare data to prod, or in some cases shame, health providers into adopting what it deems best practices.

In 1987, the Health Care Financing Administration, a predecessor to the Centers for Medicare and Medicaid Services (CMS), released information on deaths that occurred the previous year within thirty days of admission for the roughly 6,000 hospitals caring for Medicare patients.

The process became more refined during the George W. Bush administration, when Medicare began collecting and posting data on the quality of care provided by hospitals, nursing homes, home health agencies and other providers. The information was posted on CMS "compare" websites, which were billed as a means for the public to assess how individual providers stacked up against each other on various quality measures.

Quality reporting by hospitals was voluntary at first, and few participated. That changed after Congress added a provision to Medicare payment legislation docking reimbursement to facilities that didn't publicly report the information, virtually all hospitals in Medicare have participated.

Doctors have successfully fought efforts to keep surgical performance data confidential. However, the Obama administration resumed the trend last May with the release of data on hospital billings to Medicare that revealed significant price disparities for the same services.

"Taxpayers have the right to understand what is being paid for, how it is being paid for," Jonathan Blum, principal deputy administrator of the Centers for Medicare and Medicaid Services, said in a conference call with reporters last week. "We are asking the public's help to check, to find waste, to find potential fraud, and to help the program spend its valuable resources more wisely."

Physicians groups have long opposed the release of the billing information on the grounds that it would result in unwarranted bias against doctors. The American Medical Association said that cost was an imperfect barometer, and that quality, value and outcomes need to be taken into account.

But the recent release was all but assured after a federal judge in Florida last June lifted an injunction on publishing the information that had been in place in 1979. Dow Jones & Co. Inc., the publisher of the Wall Street Journal, had challenged the injunction, backed by the Department of Health and Human Services (HHS).

Paul Ginsburg, former executive director of Medicare's Physician Payment Review Commission and now a public policy professor at the University of Southern California, said the data will help insurers make assessments of physicians and possibly trim those doctors who run up costs.

"This is going to make it much easier, more stable, more reliable to make assessments of physicians because often insurers don't have enough data from their own enrollees" to make judgments about physicians, Ginsburg said.

Hospitals, accountable care organizations, and other networks of providers will also use the information to decide which doctors they want to do business with, he predicted. Certain group practices will also use the data to make recruiting decisions.

"I don't see a lot of direct use by individual consumers," Ginsburg said. "Consumers need an intermediary to use this for them. I don't think too many consumers can use it directly."

Former Centers for Medicare and Medicaid Services Administrator Thomas Scully predicted trial lawyers will closely examine doctors' practice patterns for signs of frequent hospital readmissions.

"These are taxpayer dollars, it's a good thing to be putting out," he said.

Experts said the data could also be used to glean how many procedures a doctor performs. Such volume assessments can be an important tool to gauge quality of care, Ginsburg said.

Ophthalmologists, oncologists and other physicians who tend to use high-cost drug treatments are disproportionately represented among the top billers. Blum and other government officials say they are looking at how treatments vary by region, and if large sums are being spent in certain parts of the country without a corresponding improvement in quality and satisfaction with care.

"We view our role as enabling a vibrant health data ecosystem," said Niall Brennan, acting director of CMS' Offices of Enterprise Management.

Publication Details