AAFP Guidance Can Help FPs Navigate Medicare Payment Data

Analysis Outlines Pros, Cons of CMS' Latest Move Toward Transparency

April 23, 2014 08:22 pm News Staff

For decades, Medicare payments to physicians were kept confidential, but after a lengthy court battle that ended last June, the records now have been opened to the public. The newly released financial data cover more than 880,000 health care professionals who collectively received about $77 billion in 2012 from the Medicare Part B fee-for-service program.

[Medicare enrollment form and social security card]

CMS recently published data showing how much physicians received in Medicare payments in 2012.

After having gone on record long ago with concerns about releasing such information devoid of context and absent any established process for physician review and appeal of errors, it should come as no surprise that the AAFP now seeks to contextualize this mountain of data.

To that end, the Academy created a dedicated Web page to help physicians communicate with patients and the media about how to properly interpret data contained in CMS' Medicare Provider Utilization and Payment Data: Physician and Other Supplier Public Use File(www.cms.gov).

The new AAFP online resource outlines the Academy's policy on transparency, specifically noting, "The AAFP recognizes the potential value of Medicare physician claims data. If used correctly, it can potentially provide accurate and meaningful information to patients, physicians and other stakeholders that could improve quality at the point of care."

Story Highlights
  • The AAFP has created a comprehensive analysis document that lends context to CMS' recent publication of Medicare payment data.
  • The analysis explains in detail how the CMS data can and should be used, while outlining the consequences of releasing such raw data in the absence of important medical context.
  • A key concern about the data is that they do not indicate the severity or complexity of conditions a physician handled during a given patient visit and, as presented, provide no ready way to measure the quality of care delivered.

To aid in properly interpreting those data, the AAFP has prepared a four-page analysis(4 page PDF) that explains in detail how the CMS site can and should be used, while outlining the consequences of releasing a raw data file in the absence of important medical context such as an explanation of the costs associated with operating a physician practice.

For example, whereas the data may attribute payments to a single physician, physician assistants and nurses also can file for Medicare payments using that physician's National Provider Identification number, so the data do not indicate that another individual under the physician's supervision actually could have performed the service.

The data became available pursuant to CMS' modification of its policy(www.federalregister.gov) earlier this year regarding Freedom of Information Act requests for information about amounts paid to individual Medicare physicians, which, in turn, followed the resolution of a protracted legal battle between CMS and the parent company of the Wall Street Journal, Dow Jones.

Publication of the data generated considerable media attention, and various reports highlighted a handful of subspecialists who receive millions in Medicare payments. Of the highest-paid 2 percent of Medicare physicians by specialty, however, family physicians ranked well below the top earners, according to an article in The New York Times(www.nytimes.com) that cited CMS' data.

All in all, the Academy's position is that the data represent yet another example of the need to move away from the fee-for-service payment model. Among the 214 million office visits that Medicare paid for in 2012, physicians and nurse practitioners were paid an average of $57 per visit. Thus, from the perspective of family physicians, the data release highlights how they have been underpaid in many instances.

Moreover, the AAFP anticipates that the data release will allow the media and public officials to take a closer look at physicians who order more expensive medications or perform costly procedures that may not be medically necessary.

Still, although the information is intended to help patients make more informed decisions about choosing a physician, comparing physicians within the same specialty is complicated because physicians who choose to subspecialize may treat very different types of patients, meaning their treatment protocols -- and, thus, the payments they receive -- could vary widely.

That, say the Academy and other groups, raises the possibility that hospitals and insurance companies could use the data to exclude select physicians from their networks because they are considered too cost-intensive.

In addition, the data do not account for the severity or complexity of conditions a physician handled during a given patient visit and, as presented, provide no ready way to measure the quality of care delivered.

Overall, the AAFP and other medical organizations have expressed concerns about the potential for errors in the data because there is no formal avenue by which physicians can correct mistakes related to their data. According to the Academy's recent analysis, however, physicians who disagree with the data attributed to them can communicate that concern to CMS via email to MedicareProviderData@cms.hhs.gov.