Milwaukee Journal Sentinel
April 17, 2014
The government's unprecedented release of information about Medicare payments to doctors last week drew national attention, particularly spotlighting individual physicians who collected millions of dollars for treating Medicare patients in 2012.
One Milwaukee eye doctor received more than $8.6 million in Medicare payments, by far the most received by an individual doctor in Wisconsin that year. A Florida doctor topped them all, receiving $20.8 million.
But the information, which disclosed the total amounts of Medicare payments made to more than 880,000 physicians and other healthcare providers, did not include the detail needed to determine what really matters: Which doctors provide high-quality care in the most cost-effective way?
"It's a lot of data. But it's not a lot of insight," said Edie Sonn, interim chief executive officer for the Center for Improving Value in Health Care in Denver.
In an attempt to remedy that, two Wisconsin members of Congress, Republican Paul Ryan and Democrat Ron Kind, last week introduced a bill to require the federal agency that oversees Medicare to release the information needed to gauge whether physicians are good stewards of healthcare resources.
The bill is similar to legislation that Wisconsin Sen. Tammy Baldwin, a Democrat, has co-sponsored with South Dakota Sen. John Thune, a Republican.
The goal is to lessen the variation in how medicine is practiced and to help control costs by identifying doctors who are more likely to order tests, perform procedures, prescribe drugs and provide other care that doesn't improve the health of patients.
The information released last week by the Centers for Medicare and Medicaid Services will be of little help in that task.
"It's not complete enough for us to use the way we are using other data," said Jo Musser, chief executive of the Wisconsin Health Information Organization, or WHIO. "That's not to say it may not be useful for some kinds of things."
The information will help identify doctors who may bill Medicare far more than their peers, for example. But Musser said, "It doesn't give you enough meat to tell you what's going on."
WHIO, which includes insurance companies, health systems, physicians, state agencies and others, has pushed the federal government to release the type of information covered by the proposals introduced by Ryan and Kind in the House and cosponsored by Baldwin in the Senate.
So, too, have the Medical Society of Wisconsin and Wisconsin Hospital Association. WHIO and similar organizations are building massive databases of medical claims from commercial insurance companies and Medicaid to determine which doctors spend more money treating similar patients than their counterparts.
The information released last week contained only part of the picture on Medicare spending. For example, fees for lab tests might be attributed to a pathologist, not the primary care physician who ordered the test.
"It tells you nothing about whether those tests were needed or not," Musser said.
What matters is the total cost of an episode of care for treating similar patients. That can vary wildly. WHIO has said it has examples of doctors in Wisconsin who use two to three times more resources than the norm to treat the same conditions.
Are an internist's patients more likely to be sent to a hospital emergency department? Does a retina specialist often use a drug that costs $1,900 instead of one that costs $50? Does a certain cardiologist put in more stents than other cardiologists?
"We know that variation exists," Musser said. "Sometimes the variation can be explained. And sometimes it cannot be explained."
To track the total cost of an episode of care, groups such as WHIO need information on hospital care, prescription drugs and other services.
"You really need additional information that this database is not going to readily provide," Sonn said.
The information on individual patients—the names are removed from the claims data—also must be adjusted for their age, gender and overall health.
An 80-year-old man with diabetes and congestive heart failure, for example, will require more complex care than a healthy 67-year-old woman.
The cost information also must be balanced with information on quality—information that also was far beyond the scope of last week's data release.
"It doesn't say anything about the overall value," said Christopher Queram, president and chief executive officer of the Wisconsin Collaborative for Healthcare Quality, a consortium of health systems, physician practices and other organizations.
The Center for Improving Value in Health Care also supports the bills introduced by Ryan and Kind and co-sponsored by Baldwin.
"It gets us to where we need to go," Sonn said.
The Centers for Medicare and Medicaid Services did not respond to a request for comment.
WHIO was an outgrowth of the Wisconsin Collaborative for Healthcare Quality, a consortium of health systems, physician practices and other organizations that first began reporting quality measures publicly in 2003.
Measuring the quality of care provided by physicians has proved to be a difficult and complex task. Measuring how efficiently physicians practice medicine has proved to be a herculean one.
"The barriers to that are just numerous," Musser said.
WHIO, founded eight years ago, hascollectedmorethan250 million claims—with patients' names also removed—from health insurers and the state's Medicaid program. More than 20 million episodes of care are found in its database.
Medicare data could potentially double the number of claims in the WHIO database.
Still, years and maybe even decades could pass before solid measures exist for how efficiently physicians practice medicine.
"The challenge in what we are trying to do is take a very complex subject and complex situation and produce useful information that's credible," Musser said.
The bills being pushed by Kind, Ryan and Baldwin would give Medicare claims data to groups such as WHIO while removing restrictions that prohibit the groups from using the data for nonpublic custom reports and from charging for them.
The Medicare information released last week is the starting point, said Rick Abrams, the chief executive officer of the Wisconsin Medical Society.
"From here, we have to make this data more complete, more timely and more accurate," he said.
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