Thursday, June 12, 2014

A different take on Medicare's release of doctor payment data

Journalists have had a good time with the Medicare data on payments to doctors. The most recent exposé is headlined "Taxpayers face big Medicare tab for unusual doctor billings" by the Wall Street Journal. Because of a paywall, most people did not have a chance to read the article.

It recounted several anecdotes about physicians who received huge amounts of money for procedures of dubious worth. I will summarize two of them.

In 2012, an internist in Los Angeles was paid close to $2.3 million for a procedure known as "enhanced external counterpulsation," or EECP, which is supposed to ameliorate angina in patients who are not surgical candidates.

Although not a cardiologist, he apparently used EECP on 615 patients. At the Cleveland Clinic, whose chairman of cardiology says the procedure should rarely be used, the procedure was performed on only 6 patients in a year—that's 6 patients total by a staff of 141 cardiologists.

A Florida dermatologist received $2.41 million from Medicare in 2012 for 15,610 radiation treatments for melanoma in 94 patients, an average of 166 treatments per patient. The usual number is 20 to 35 treatments. The doctor said he billed for each lesion separately and treated each one about 40 times.

A radiation oncologist who was interviewed questioned the appropriateness of the machine the dermatologist was using and said, "When a patient has several lesions, they commonly get treated simultaneously and are billed for as a single treatment, he said."

That is the way Medicare handles most multiple procedures. At best you might get away with billing a partial amount for an additional treatment.

Any physician who has spent time in the private practice of any medical specialty that involves the treatment of elderly patients can tell you that Medicare will nickel and dime you to death over a minor dispute about an evaluation and management code.

Medicare is also notorious for holding back money due to physicians who are just trying to make a living. A classic ploy is to request a copy of the dictated operative note for a simple procedure. This will add 4 to 6 weeks to the eventual cutting of a check.

They routinely perform unannounced on-site audits of doctors offices looking for discrepancies in documentation. I once experienced one myself and luckily was not cited or fined.

Here are some questions that I haven't seen any journalist ask.

Why does the Wall Street Journal have to point out such flagrant outliers? What does the Wall Street Journal know about detecting these practices that Medicare could not do for itself? How can Medicare continue to pay top dollar for questionable treatments and billing practices? Why doesn't Medicare do something simple like automatically reviewing any practice that receives more than say $500,000 in a single year?

Inquiring minds want to know.

What's your opinion?


WhiteCoat said...

Which is worse? A few outliers that make the profession look bad or an inept healthcare system that keeps paying the outliers for questionable charges?

Skeptical Scalpel said...

(c) All of the above

DCanes said...

Nevertheless... bad apples should be exposed. Why not WSJ for this job? Who else? Vast majority of physicians are decent and honest. Most of us have nothing to hide with this data out in the open. Also, questionable behavior changes simply by releasing the data, then Medicare won't have to waste as much time/money stamping out fraud.

George Gasman said...

Being on the receiving end of a billing company, I am shielded from many of these disclosures. I am grateful for that. Being close to retirement, I am less than enthusiastic about getting my dander up about these disclosures.

HOWEVER, looking at the reimbursements that I've gotten for things like an arterial line, a bowel resection at 2 AM on an ASA Class 4 patient, I can't help but think of the plumber comments.

SS, your questions are good - why stoke the fires of outrage by citing the outliers? I tell patients what I get paid for procedures (like a cataract - frequently among the oldest, sickest and most frail of patients), and they are shocked.

Skeptical Scalpel said...

DC, I may not have made this clear. I have no problem with the Wall Street Journal publishing a story about unusual billing practices. My problem is why can't Medicare police itself? They had access to the data. Why can't they confront the outliers?

George, these things need to be spotlighted. But it shouldn't have been the result of reporters digging up this information.

Anonymous said...

Given how outrageous these outliers seem to be on the surface, one has to suspect there is a level of willful neglect. Perhaps those smart/unethical enough to bilk the system out of millions of dollars are also diverting a portion of the profits toward someone who can influence the audit process...

Skeptical Scalpel said...

You may be right. Who knows? It is very curious that these cases have only come to light now.

Anonymous said...

Yes that is true that people use their positions for others. The publisher of the Albany (NY) Times Union. Hearst also sits on the board of St. Peter's Health Partners, which, following a merger, operates three of four hospitals in the Albany area. For 14 years Hearst's newspaper hasn't printed anything about the lawsuits against them but got $$$ for advertising. The same I suspect is true with the Va. Pilot, as I have asked the same questions because of their advertising $$$ and why they didn't check out a story about missed/delayed diagnoses, alleged HIPAA violations and retaliation, patient abandonment, gang stalking, etc.

Skeptical Scalpel said...

Interesting angle which I had not thought about. Newspapers have incentives to not offend major advertisers.

Anonymous said...

Exactly. Let me point out one other issue: state medical boards are starting to get more notoriety regarding the lack of action against problem docs. Lets face it: problem docs make the good docs look bad. They make the system look worse. When medicine doesn't police itself, you then allow lawyers and the government to do it to you because no one is going to believe any one else is doing anything about the problem.

The only thing worse than a bad doctor is a lawyer and the government running something.

Doctors really did it to themselves by retaliation and not reporting its own. Better to report ones own than be hit by lawsuits, but that's not the way medicine thinks. Blacklisting and the like only makes the distrust go farther.

Skeptical Scalpel said...

Anon, thanks, but I don't quite understand your last paragraph--particularly the parts about retaliation (against whom?) and blacklisting (who is the blacklister and who is the blacklistee?)

Anonymous said...

Retaliation against patients or former patients. I've had a nurse make a comment that was not positive about a patient at a party. I've had a doctor who made it clear he would ruin my relationships with other doctors if I didn't consent to a test. That doesn't include some blatant changes/additions to records because they either did something illegal or missed something and were trying to fix it. Doctors who made it clear they would give no care if you made them mad. Behaviors like that, clearly witnessed by others in the healthcare profession, and not one thing done about it. It should be made easier in the medical profession to report behaviors and events one sees without retaliation from the one getting complained about and it should also be mandatory repercussions if one doesn't report. Doctors blacklisting patients - or hospitals doing it. I've seen that happen: one doc got reported for a s*x harassment suit by several women and the women got banned from all but EMTALA care in the area. By law (at least in this state), cooperating with govt. people on a complaint and getting retaliated against is illegal and unethical, immoral too, but the hospitals did it. Btw, the doc gave up the license because he knew the evidence was against him.

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