No advantages from circulation of physician payment data, doctors say

Release of 2012 physician payment data from the Centers for Medicare and Medicaid Services (CMS) has perhaps done a disservice to the reputation of healthcare providers including dermatologists, say several dermatologists.

The dissemination of Medicare payments in early April, showing that 880,000 physicians and other healthcare providers received $77 billion under the federal program, received much attention in the lay media including in high-profile daily newspapers such as “The New York Times.”

The data suggested that some specialists, such as ophthalmologists and oncologists, were billing much more than their confreres in dermatology. The data also revealed that a small minority of physicians, about 100 out of a possible 880,000 physicians and other healthcare providers, received a total of $610 million that year. A small fraction of the total was responsible for about one-quarter of the $77 billion total that was paid out that year.

The information has largely been regarded as more damaging than helpful to practicing dermatologists.

“There are efficiencies such as dermatologists managing skin cancer in their offices, and the accompanying charges that are submitted to Medicare are lower than if the patients were treated in hospital,” says Steven Feldman, M.D., F.A.A.D., a dermatologist and professor of dermatology at Wake Forest University School of Medicine, Winston-Salem, N.C.

Lacking interpretation

The data do not provide interpretation, such as where dermatologists are geographically based or what their particular area of specialization is, that may explain some variation among doctors, Dr. Feldman says.

“You might expect that rates of treatment for skin cancer would be higher for dermatologists who work in Florida,” Dr. Feldman says. “It may appear in some cases that a dermatologist is prescribing a ton of biologics. But that dermatologist could be a psoriasis expert, who is being referred the worst of the worst cases, which is why so many biologics were being prescribed.”

But Dr. Feldman stresses that “as someone with libertarian tendencies I am in favor of the public’s right to know.” Indeed, making these data a matter of public record provides patients with the opportunity to look at services for which physicians billed, he adds.

Moreover, bringing these data into the public realm could shed light on which doctors may be routinely billing for unneeded measures, according to Dr. Feldman.

“For example, there may be doctors who are billing routinely for immunostaining on basal cell carcinomas which is not necessary,” he says. “We should all want to ferret out that kind of fraud. Presentation of these data may make it easier to identify problem outliers.”

Next: Does initiative pit specialists against each other?

Creating divisiveness

The fallout from this CMS initiative is that it will create divisiveness in the physician community, contends Joel Schlessinger, M.D., F.A.A.D., F.A.A.C.S., a board-certified dermatologist in Omaha, Neb., and chief editor, cosmetic surgery, “Practical Dermatology” magazine.

“It is pitting specialty against specialty,” Dr. Schlessinger says. “This engenders greed and discord when salaries of dermatologists are published in such a granular fashion.”

Without proper analysis, the data can be significantly misunderstood, he says.

“The information is terribly open to misinterpretation,” Dr. Schlessinger says. “There are so many facets that the public does not understand, and none of these figures are easily digestible to the public. The perception is likely to be that unethical physicians bilk the system. Some dermatologists are in higher ranks of paid physicians due to being in complex practices with numerous physician extenders, tertiary care referrals or medication costs and this could be misinterpreted as well.”

Still, the public circulation of these data can perhaps serve to identify physicians who are displaying egregious behavior by overbilling Medicare fees, but it remains to be seen if these physicians will modify their billing practices.

“The problem is that most of the unethical physicians who are exhibiting this sort of questionable behavior likely already know they are out of line (with their colleagues), and simply refuse to understand that every Mohs surgery case does not need to be three or four stages and not every skin cancer requires a flap or graft for closure,” Dr. Schlessinger says.

More accurate billing

The “silver lining” to this news is that it may produce changes in billing and coding practices that could encourage more proper coding/billing, he says.

Another spin-off of this news is that it may also illuminate the fact that most dermatologists are treating a less remunerable population that would likely go without care were it not for Medicare.

“The majority of dermatologists who accept Medicare patients are providing services at a significant discount to insurance carriers and serving a population that would otherwise go unserved,” Dr. Schlessinger says. “If anything, dermatologists are underbilling for services.”

The dissemination has also raised the issue of whether physicians will continue to include Medicare patients in their practices, he says.

“If the data start to have negative repercussions on dermatologists and their good standing amongst the public, it could force some dermatologists to quit Medicare entirely,” he says.

Terrence J. Cronin Jr., M.D., editor-in-chief of “Dialogues in Dermatology,” the monthly audio journal published by the American Academy of Dermatology (AAD), agrees with Dr. Schlessinger that this diffusion of data will cause a rift in the community of physicians.

“This was meant to be divisive amongst physicians,” Dr. Cronin says. “I am very disappointed that this was done. It was a negligent and unwise measure.

“By the release of this information, the government has made physicians targets,” he continues. “Criminals may victimize physicians listed in the data dump. I also worry about the top billing physicians being targeted by malpractice attorneys as deep pockets. This could have been done without identifying individuals publically. It is really irresponsible, and it's meant to harm all physicians.”

Next: The AAD's position

AAD’s stance

For its part, the AAD has expressed concern about the dissemination of this information. While the AAD appreciates the move was one to increase transparency about Medicare costs to the public at large, the absence of perspective about the meaning of the data could lead to inaccurate conclusions, according to AAD president Brett Coldiron, M.D.

“The broad release of Medicare physician payment data without appropriate context could hinder patient understanding about the value of appropriate, medically necessary healthcare services as recommended by their physician,” Dr. Coldiron stated in an email response. “Reimbursement data and procedure reimbursement rates alone are not an indicator of high-value care. These data must be coupled with quality, outcomes, and patient experience data, as well as a specific analysis of individual physicians’ patient population and service mix, to present a more accurate reflection of value.”

Dr. Coldiron went on to write: “It may not be clear to patients, for example, that practice expenses are included in the CMS payments, which could account for as much as 60 percent of payments. Other items that were not included in the data release include: how much of a physician’s patient base consists of Medicare patients; what types of cases physicians typically treat; quality of care; how many non-physician clinicians provider services bill under the physician’s number. All of these factors are important in interpreting the data that was released by CMS.”

All physicians have “an ethical obligation to treatment,” Dr. Coldiron stated. “I personally will continue to treat patients according to their medical need, and not their healthcare coverage.”

Disclosures: Drs. Feldman, Schlessinger and Cronin report no relevant financial interests.