August 24, 2019
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Long-secret Medicare data reveal payments to Maine doctors

John Clarke Russ | BDN
John Clarke Russ | BDN
Geoffrey Gratwick

More than 20 Maine health providers were paid at least $1 million each from Medicare in 2012, according to a trove of government data released Wednesday that sheds unprecedented light on health care billing across the country.

Of the 23 receiving at least $1 million in Maine, seven were clinical labs or ambulance providers. Individual doctors and surgical centers accounted for the remainder.

Health providers in Scarborough received the top two Medicare payments in Maine. NorDx, a clinical lab that operates under the MaineHealth system, was paid nearly $4 million, the data show. Northeast Mobile Health Services, which describes itself as Maine’s largest ambulance service, was paid $3.4 million in 2012 by the government health insurance program for seniors.

Experts warned the easily data could be misconstrued . While high payment amounts may serve as a red flag for fraud, they don’t necessarily indicate any wrongdoing or reflect a health provider’s salary.

The data revealed individual physicians’ billing practices for the first time nationwide, including the number of visits and procedures and how much doctors were paid. The information, which includes 880,000 providers, was off limits to the public for more than three decades while the American Medical Association successfully fought its release. A federal judge recently lifted that injunction.

The Medicare payments account for a significant chunk of overall medical payments in an older state such as Maine. About 20 percent of Maine’s population, roughly 275,000 residents, is insured under Medicare, the federally funded health insurance program for those ages 65 and older and people with disabilities.

“This is a big deal for Maine because Maine does have proportionally a higher percentage of population in the Medicare program, simply by virtue of our age structure,” said Andrew Coburn, a rural health expert and chairman of the Master of Public Health program at the Muskie School of Public Service at the University of Southern Maine. “As a result, health care providers are more dependent on Medicare than in most other states.”

In Maine, rheumatologists, who treat joint, tissue and autoimmune problems, and ophthalmologists, who treat eye diseases, rounded out the top 20 payments, along with several cancer doctors. All tend to see a large proportion of older patients.

Officials with the Obama administration said releasing the data would give researchers, policymakers and the public a new glimpse into health care spending and physician practice patterns. Publicizing the payment data also may expose fraud in the system, officials said.

While high billers may attract the attention of government fraud inspectors, legitimate doctors may get big payments. The data show only payments to doctors by Medicare, not any private insurers. Doctors who treat a high proportion of Medicare patients, and fewer patients with other forms of health insurance, may bill the program for larger amounts. Physicians also may provide services such as eye surgery that are reimbursed at higher rates, or use much of the money to pay overhead costs, such as for medications and staff payroll.

Some doctors care for a sicker group of patients, which also could lead to higher payments.

Michael DeLorenzo, director of health analytics at the Maine Health Management Coalition, which publishes score cards on hospitals and doctors, applauded Medicare for releasing the data. But more analysis remains to understand how to use the information to improve the cost and quality of health care, he said.

“Just getting this data out there is just the beginning,” he said. “I think it needs a lot of work to put it in proper context.”

Maine providers

Medicare paid nearly 5,800 Maine doctors and other health providers to treat the program’s beneficiaries in 2012, the data show.

The information reflects payments to doctors under Medicare Part B, the portion of the program related to medical care. It doesn’t include hospital charges beyond a physician’s fee, such as room and board, prescription drugs or any expenses incurred under supplemental Medicare Advantage plans or private insurance.

No identifying information about patients was released.

A NorDx spokeswoman said its Medicare payment was high because of the volume of testing performed by the lab, the largest in Maine. NorDx provides lab services for all of MaineHealth’s nine hospitals, plus 110 nursing homes and 20 walk-in testing centers. The $4 million represents nearly 470,000 tests over eight months, she said.

Dr. Robert Sylvester, a Lewiston rheumatologist, topped the list of Medicare payments to individual Maine physicians at $2,379,244 in 2012.

Like others in his field, Sylvester foots the bill up front for a number of expensive injection medications, then gets reimbursed by Medicare, he said. Much of that more than $2 million accounts for drug costs, he said.

“We do a lot of sick patients,” Sylvester said. “We do use IV medications which are very strong, and expensive.”

Sylvester gets reimbursed only about 5 percent more than some drugs cost, with the extra money going toward staff’s salaries, supplies and overhead expenses, said Reuben Allen of Wilmington, N.C., a business consultant for the practice.

Allen described the data as a “misrepresentation” of the practice’s work, saying it showed an exceedingly high and inaccurate number of one type of arthritis drug injections. He didn’t take issue with the total dollar figure. A physician assistant also bills under Sylvester’s code, a common practice.

“I wish for Dr. Sylvester it was true that all this money was coming into his pocket,” Allen said.

Dr. Geoffrey Gratwick, a Bangor rheumatologist and state senator who has pushed legislation to better publicize hospital prices, was torn about the data release. He cheered the transparency, saying patients should know how much doctors are paid, but said the data wildly overstated the amount of one arthritis medication he administered to patients.

“It’s not going to make our medical system, but it’s part of the puzzle,” he said of the data release. “I think people should know how much they’re going to pay for a car or a washing machine or a knee replacement.”

Medicare listed Gratwick as the 33rd highest-paid provider in Maine, with $795,260 in payments in 2012. He said the total was wrong, adding that the bulk of his Medicare payments went toward drugs and overhead costs.

“I wish my salary was $795,000,” Gratwick said.

The American Medical Association long fought against the release of Medicare payments to individual doctors, arguing the data could mislead the public and unsuccessfully lobbying for doctors to correct any errors before publication. In May 2013, a federal judge lifted a 33-year-old injunction that barred the government from publicly releasing the data, which grew out of a lawsuit filed by the doctors’ association.

The Wall Street Journal, along with consumer groups, pushed the government for years to release the information.

Gordon Smith, a spokesman for the Maine chapter of the American Medical Association, said the public should understand that the Medicare payments don’t include doctors’ costs, such as malpractice insurance.

“We are not opposed to the release of this data,” he said. “Our concern would be … that there’s been no opportunity to check the accuracy and that consumers may well be misled by it.”

The Maine Osteopathic Association said in a statement that it welcomes accountability in health care costs, but worried the data painted an incomplete picture of physician reimbursement and should have been reviewed by doctors before public disclosure. The association largely represents family doctors, who barely show up in the Maine data.

Medicare reimbursement hasn’t kept up with the cost of providing medical services or related business expenses, the group said in a statement.

“It is not clear how patients will use this data or if it would be of any help in the consumer decision-making process,” the statement read.

The data’s limits and possibilities

The data released Wednesday was redacted to exclude any services provided to fewer than 11 patients to protect their privacy. Officials with the Centers for Medicare and Medicaid Services, which oversees the program, said the redaction cut out about 15 percent of all payments nationwide.

While the data show the volume of procedures and how much they cost Medicare, it includes nothing about the quality of the care provided, Delorenzo noted.

“We fully support the transparency, but we just think there’s a lot of work to be done around the data to really understand what it means,” he said. “And then how to make it useful to improve care, both on the quality side and work on reducing costs, thereby increasing value.”

The data reveals variations in how much doctors charge both across states and across specialties within states, Coburn said.

“There’s a lot going on in these data that raise a lot of questions but don’t necessarily yield clear answers,” he said.

In Maine, the average annual Medicare payment in 2012 totaled $52,000, about a third the amount doctors actually billed the program. That’s far lower than places such as Florida, at an average of $144,205, but higher than other states such as North Dakota, at $48,000. Maine providers have long argued that Medicare’s complicated payment formula, which includes geographic variations, puts the state at a disadvantage when compared with others, Coburn said.

As for how consumers might use the new data, Coburn said Medicare beneficiaries are largely insulated from paying much out of pocket. Many buy supplemental insurance to cover any expenses Medicare doesn’t. Consumers with high-deductible plans or stiff co-pays and coinsurance, on the other hand, have more incentive to see how much their doctor charges compared to another, he said.

“If you have a $5,000 deductible, you will shop around,” he said.

BDN User Experience and Audience Manager Pattie Reaves contributed to this report.

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