The public is getting its first glimpse of physicians’ Medicare claims data following a widely publicized data release Wednesday by the Centers for Medicare & Medicaid Services (CMS). But because the agency released only raw data with little context and considerable limitations, it’s easy for patients, reporters and others to draw inaccurate conclusions about individual physicians.
For doctors who are receiving inquiries from patients or reporters about their charges or payments, giving a response that provides context for the data may be in order. While circumstances will vary on a case-by-case basis, here are some of the most important points to clarify.
Medicare payments aren’t the physician’s personal income
These payments are practice revenues that must cover business expenses, including pay and benefits for practice staff, billing and other professional services, office rent, utilities, professional liability insurance, medical equipment and supplies.
The average breakdown, according to CMS’ Medicare Economic Index (MEI), places about half of payments into one of these other expense categories.
Depending on the physician’s specialty, location, practice type, patient mix and other factors, the percentage physicians actually take home as their personal income can be much less than the MEI estimate.
In addition, the Medicare claims data released includes reimbursement for drugs the physician administered, which is not figured into the MEI payment breakdown. CMS fails to explain in the data release that doctors purchase drugs and that Medicare payments simply cover the price of these services—many of which are very expensive and are required to treat such serious conditions as cancer and macular degeneration.
The majority of physicians don’t receive noteworthy Medicare payments
Despite some attention-seeking news headlines that focus on sizeable pay-outs to physicians, the average physician doesn’t generate that much revenue from Medicare payments. In fact, 75 percent of physicians and other health care professionals receive less than $85,000 per year in Medicare payments as reported in the CMS data file. The median payment amount is scarcely more than $30,000.
Attribution issues could distort the data
Because the data is tied to the National Provider Identifier (NPI) under which the services were billed, some physicians who provide Medicare services may not be included in the data at all because their claims were filed using a group NPI. Other physicians may be included in the data release, but the services attributed to them may not reflect the care they actually gave because some of those services were reported using their group NPI.
Similarly, some physicians may appear to have provided fewer services than they did because CMS excluded services that were performed for 10 or fewer Medicare beneficiaries to protect patient privacy. For instance, the data for some surgeons reports only their evaluation and management codes, not the procedures.
On the other hand, some physicians may appear to have a higher number of services because their data is attributed with services and payments provided by other clinicians in their practices, including residents and other health care professionals. Even when the data is complete, the way it is displayed my lead to misinterpretations, such as the appearance that surgeons working with an assistant at surgery have performed an inflated number of procedures.
The data isn’t about quality
The claims data focuses on payment amounts and number of services provided but doesn’t provide explicit information about quality, such as outcomes, necessity and comparison to services provided to non-Medicare patients.
The data shows only a portion of the full picture
Patients and others shouldn’t make an assessment of their physicians based on the Medicare data alone because it only provides a subset of information. For instance, claims data isn’t included for patients who are covered by Medicare Advantage plans, private insurance or Medicaid.
At this point, CMS has denied requests to establish a process for physicians to report inaccuracies in their data. The AMA continues to press the agency to provide a feedback mechanism for correcting errors.
Additional information about the Medicare claims data release and resources to help navigate this issue will be posted to AMA Wire™ throughout the coming days and weeks.
