On April 10th, Medicare released what the New York Times called “the most detailed data ever released in Medicare’s nearly 50-year history.” The dataset contains physician charges, medicare payments, and beneficiary utilization of physician services from the year 2012. Users can download the dataset and perform analysis on it.
In fact, it is very easy to view data about individual doctors and their billings to Medicare because the data is aggregated at the NPI (national provider identifier) and HCPCS (healthcare common procedure coding system) code level.
According to Medicare chief Jonathan Blum’s open letter to the Executive Vice President and CEO of the American Medical Association, one goal of the data release is to “assist the public’s understanding of Medicare fraud, waste, and abuse”. Many journalists have already written stories that highlight findings from the dataset. A quick search online pulls up and article by Charles Ornstein and Ryan Grochowski Jones on ProPublica. They highlight several doctors who consistently billed Medicare at the highest charge possible for procedures performed on their patients.
This raises some ethical questions about the nature of this release, including questions about physicians’ rights to privacy and the effectiveness (and by extension potential ineffectiveness!) of the almost “crowd-sourced” nature of fraud detection activities.
Jonathan Blum addresses the issue of physician privacy in his open letter to James Madera (link is above) and makes a compelling argument for why the public’s interest in having access to physician charges outweighs physicians’ desires for privacy on the subject.
The least interesting but most compelling argument is a legal justification which points out that the organization is required to release the data under the Freedom of Information Act (FOIA). According to Blum, CMS has received “multiple FOIA requests, seeking physician Medicare payment information. According to the FOIA, an agency is required to make frequently requested materials available electronically after the material has been reviewed under the FOIA.”
While this is perhaps the most objective justification for the release of the data, it is certainly not the most interesting one. Perhaps more compelling is the notion that publicly available data could help expose fraud, waste and abuse. To illustrate this, Blum cites a Wall Street Journal article that identified and reported instances of Medicare fraud and abuse by analyzing CMS data. The article was the Wall Street Journal’s “Secrets of the System” series, which explored Medicare’s databases in an effort to demonstrate how they could be used to expose fraud and abuse in provider’s billings.
Blum also argues that the release will provide opportunities for the public to educate themselves on Medicare’s internal operations, including the cost of payments made to doctors which are “governed by statutory requirements that CMS must follow.” This suggests that an underlying goal of this particular open data initiative is to use it as a soft political tool to scrutinize Medicare’s allowable charges. Blum makes it pretty clear that this is exactly what he means later on in the letter when he says, “[releasing the data] will also allow a more informed debate about the appropriate Medicare payment for particular services.”
Finally, and perhaps most revealing about the future of the healthcare industry in general, Blum argues that physicians no longer have the luxury of keeping their billings private. He argues that the landscape has changed and cites provision 10331 of the Affordable Care Act, which requires the Secretary of Health and Human Services to make data about the quality of physician services available on the Internet (a.k.a. the “Physician Compare” initiative). ”Section 10331(c) of the Affordable Care Act specifically requires the Secretary to ensure patient privacy when making information publicly available,” says Blum, “but the requirement does not contain a provision for physician privacy.” He goes on to say, “This may reflect the changing nature of what information is publicly available about physicians’ services and payments.”
And he’s right. From the recent IPO of Castlight Health to the announcement that major payors will be making medical prices more transparent, the industry is teeming with activity around cost transparency. Todd Hixon’s blog on Forbes.com explains how cost transparency is in fact creating a whole new business model for startups within the healthcare technology space.
With all of this activity, I think that Blum is right. Consumers are demanding that physicians’ charges become more transparent. Consumers want to be able to shop around for medical services and compare prices, and they will only be able to do that if they know what physicians are charging.
But I also believe that transparency can only go so far. Does a consumer need to be able to determine, for example, how much a physician was paid in total in any given year (something that can easily be done using the dataset that was released)? Doesn’t a physician have a right to keep his or her total income private, even if the individual rates for procedures are public? Also, should individuals (both journalists, technologists, and researchers) really be encouraged to root out fraud within the dataset and then publish their findings about specific doctors (with their full names) on websites without any external validation of their methodologies?
Yes, the future of the industry is to open up prices and make them available to the public. And yes, we need qualified experts identifying fraud and prosecuting physicians who abuse the system. So I do believe that releasing the physician charges and utilization data is a step in the right direction.
Let’s just hope that it doesn’t lead to a witch hunt.
I plan on looking through some of this data and explaining it here on this site. I’ll also be using it to learn more about D3.js and how it can be used to create dynamic visualizations of data. You can find and download the Medicare data here.
Image courtesy of Ray Bouknight on flickr