SUMMARY: A big pile of Medicare doctor payment data was released today. That’s great for transparency, and great for public debate. It’s also a big step toward understanding some of the vagaries of our health care system.



The data reveal Medicare payments by provider for 2012. There are some big surprises, and also some ho-hum moments. And a need to delve deep, to ask questions, and to understand.

The numbers are messy, and there are a lot of them. The early stories have focused on broad strokes.

“A tiny fraction of the 880,000 doctors and other health care providers who take Medicare accounted for nearly a quarter of the roughly $77 billion paid out to them under the federal program, receiving millions of dollars each in some cases in a single year, according to the most detailed data ever released in Medicare’s nearly 50-year history,” write Reed Abelson and Sarah Cohen in The New York Times.

“In 2012, 100 doctors received a total of $610 million, ranging from a Florida ophthalmologist who was paid $21 million by Medicare to dozens of doctors, eye and cancer specialists chief among them, who received more than $4 million each that year.”

There are 35 ophthalmologists in Florida making 7 figures and up from Medicare annually. That’s a huge amount of money, and it seems obvious that the $21 million winner has lots of company — with a lot of retirees in Florida, that makes a certain amount of sense. But still….

Caution on drawing big conclusions

Data is a blunt instrument. Numbers alone don’t tell a story: it’s deeply important that people who understand the system have a chance to look at the data and assess it for significance. Millions of dollars spent don’t automatically mean someone’s doing bad things (although they can be a good signpost toward wrongdoing).

Among those urging that we approach the data with caution is Charles Ornstein, one of the nation’s best health-care journalists, who writes over at ProPublica.

“There are many reasons why a doctor may receive large payments from Medicare,” writes Ornstein on the Association of Health Care Journalists blog. For one, the doctor may treat exclusively Medicare patients. In such cases, the doctor’s payments would naturally look larger compared to peers who also see a lot of privately insured patients (this is called a provider’s payer mix). Another explanation is that the doctor may provide services, such as eye surgery or cancer care, that are reimbursed at higher rates than typical office visits. A third explanation is that the provider may have other professionals billing under his/her Medicare number, which is allowed in some circumstances.”

We’re 100 percent with him: We’ve seen earlier data releases from Medicare that needed to be approached only with a gas mask and other protective gear. We’ve also seen data that ascribed a massive number of charges to one provider, when in fact that provider was the up-front name for several hundred providers in a group practice, and there was no wrongdoing.

If you’re a do-it-yourselfer, here are tools

If you’re a do-it-yourselfer, here’s some help from data maven Fred Trotter over at DocGraph: a handbook for digging in the data.

For do-it-yourselfers, here’s the original source, from the Centers for Medicare and Medicaid services. Careful about downloading it all in bulk. It might crash your computer.

The wisdom of the crowd

One of the great things that comes out of a release like this is that the information is sorted and culled by journalists and others, and made available in a digestible way. That didn’t happen when the information was locked away in government vaults. Now that it’s out in the wild, people can see it.

The people and the docs who are reading the data and using the tools supplied by The Times, The Wall Street Journal and others (some of whom got an advance look at the data and were thus able to put together great tools) have things to say about the results.

They can look at the search tools, and they can see things journalists might not. Here’s the Wall Street Journal search tool, and here’s the one from The New York Times.

‘Grossly underestimated how much I actually received’

One doctor said: “Funny…but it grossly underestimated how much I actually received from Medicare in 2012, but egregiously overestimated how much one of my partners received in 2012. It also included a physician in our practice that has been retired for 8 years! This is not the most accurate data reporting and obviously is being used for ulterior motives such as justifying reductions in payment to certain specialties, which do get alot from CMS but also have equally high overhead due to the exorbitant cost of the medications (i.e.hematology/oncology)”

One commenter at The Times said this: “For those critical of doctors receiving medicare dollars: Physicians can still choose whether or not to accept the comparatively low-reimbursement with medicare. (Obviously some physicians are gaming the system and should receive scrutiny). Kudos to those physicians who take the time to spend 20 minutes with a patient for $57. (This hardly pays for overhead in most practices). “

Doctors paying for medications: differing amounts

Another doctor, this one an ophthalmologist from St. Louis, complained that the numbers unfairly pillory him and his colleagues, who use an expensive drug that they have to buy, then wait for reimbursement.

“Those whopping reimbursements for ranibizumab do not end up in the ophthalmologists’ pockets,” he wrote. “We buy ranibizumab from Genentech at $1800 a dose and then wait for Medicare to reimburse us. So instead of rolling in cash, we cover our costs with the very thin margin between our cost and the reimbursement. Furthermore, we now have the bookkeeping headaches from keeping track of the stuff. Maybe the New York Times should look into why CMS is willing to pay Genentech (through us, their fence) $1800 for Ranibizumab when the alternative, Avastin, costs about $50 a pop. Sloppy and infuriating distortion of what is really going on. The folks at Genentech will be sitting back at their breakfast table, smiling, while they take in this deflection of responsibility.”

Another writes: “This article needs to give the details of the cost of the injections given for macular degeneration in order for the article to better inform it’s readership. For an injection of Lucentis, the ophthalmologist gets a total of $2,111.86, but out of that, he must pay the drug company $1,950 for the medication. If you take that pass thru payment to the drug company out of the equation, it paints a much different picture, doesn’t it?”

Careful readers will note that one doc pays $1,800 for his Lucentis, and the other pays $1,950.

Commenting on the Florida ophthalmologist

“Well the saga of Dr. Melgen just got a lot more interesting. It seems he has a history of involvment with the top political leaders of FL and the White House. It also seems his background was manufactured out of whole cloth. He does have a MD certification from a small teaching hospital in MO and had nothing to do with Harvard or Yale.

“His background origin is from the Dominican Republic and the FBI has raided his office and investigated his flying Senator Menendez to Dominican Republic. Do a google on Menedez and he does have a checkered past”

Another commenter also picked up on that thread: “Without mentioning his name, but interesting is that the Florida ophthalmologist mentioned in this article who was paid $21 million by Medicare happens to be the very medical professional tied to New Jersey Senator Robert Menendez involving an earlier sordid scandal and investigation since dropped. Perhaps the klieg lights of the press will now do a swift 180 in the garden state and focus their illumination into the dark corridors of the Senator and DNC where they always belonged and away from the Governor they fear. Somehow I doubt it. “

A third wrote: “Salomon Melgen, a Florida ophthalmologist who specializes in injections for age-related macular degeneration, was paid $20,827,341 in 2012, or 64 times the average in his field, the data show. His appeal of a 2009 ruling that found he overbilled Medicare by $8.9 million was rejected last year. Farid Fata, a Michigan oncologist paid $10,063,281 in 2012, was charged with Medicare fraud in August, according to court records. The data opens fresh questions about Medicare’s payment policies.”

Praise for docs, and some more caution

And another thoughtful commenter said: “Doctors do often spend more than half an hour with each Medicare patient. And receive $57 for their trouble. After 12 years of post high school education, this is hardly excessive. By all means investigate the physicians receiving a net, millions of dollars a year. (After deducting their own costs for the special medications the office is administering.) My concern is that the release of this data is going to cause many to rush to judgement. And potentially to reduce the fine medical care that our seniors are entitled to receive, after all, Americans work upwards of 40 years to earn their Medicare.”

We used to live in a world where all data was sorted and assessed by journalists who orated from a mountaintop down to the assembled masses. That’s changing: the assembled masses, our communities, are now helping our reporting.

Perhaps none of the commenters mentioned here are informed, or thoroughly informed, or as authoritative as the journalists who are even now assessing the information. Perhaps these commenters are “just some guy on the Internet” and deserve no credence.

To the people who say their data is wrong: It’s great to have their data in a place where they can see that, perhaps pointing them toward better data collection, which in theory would contribute also to the common good. And what about those differing prices for a very expensive drug? And what about Medicare’s payment policies? Great questions, all.

We’re huge advocates of transparency. Though transparency can be messy.

The general sense of a crowdsourced reporting endeavor, sparked by the Obama administration’s decision to release the data even if it was known to be potentially messy, gives great hope that some of the darker byways of the health-care marketplace can be illuminated.



Jeanne Pinder

Jeanne Pinder  is the founder and CEO of ClearHealthCosts. She worked at The New York Times for almost 25 years as a reporter, editor and human resources executive, then volunteered for a buyout and founded...