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Originally published Tuesday, April 8, 2014 at 10:50 PM

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Medicare opens its books on doctors, hospitals

The Medicare data — all for 2012 — is considered the richest trove of information on doctors, surpassing what major insurance companies have in their files. In 2012, 100 doctors received a total of $610 million, including a Florida ophthalmologist who got nearly $21 million.


The New York Times and The Associated Press

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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 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. A Florida ophthalmologist got nearly $21 million.

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

While more money by far is spent for routine office visits than any other single expenditure, one of the most heavily reimbursed procedures — costing a total of $1 billion for 143,000 patients — is for a single treatment for an eye disorder common in the elderly.

About 1 in 4 of the top-paid doctors — 87 of them — practice in Florida, a state known both for high Medicare spending and widespread fraud. Rounding out the top five states were California with 38 doctors in the top group, New Jersey with 27, Texas with 23 and New York with 18.

In the $3 million-plus club, 151 ophthalmologists — eye specialists — accounted for nearly $658 million in Medicare payments, leading other disciplines. Cancer doctors rounded out the top four specialty groups, accounting for a combined total of more than $477 million in payments.

The Medicare data — all for 2012 — is considered the richest trove of information on doctors, surpassing what major insurance companies have in their files. Although Medicare is financed by taxpayers, the data have been off-limits to the public for decades. Physician organizations went to court to block its release, arguing it would amount to an invasion of doctors’ privacy.

Employers, insurers, consumer groups and media organizations pressed for release. Together they argued that the data could help guide patients to doctors who provide quality, cost-effective care. A federal judge last year lifted the main legal obstacle to release, and the Obama administration recently informed the American Medical Association it would open up the claims data.

“It will allow us to start putting the pieces together,” said Dianne Munevar, a top researcher at the health-care-data firm Avalare Health. “That is the basis of what payment-delivery reform is about.”

Fraud investigators, health-insurance plans, researchers and others will spend weeks poring over the information about how many tests were ordered and procedures performed for every provider who received Medicare payments under Part B, which excludes payments to hospitals and other institutions. The Centers for Medicare and Medicaid Services is making the data available Wednesday.

While total Medicare spending — including hospitals, doctors and drugs — is approaching $600 billion a year, payments to individual doctors have long been shrouded in secrecy. Medicare paid $12 billion for 214 million office and outpatient visits, most of them described as between 15 and 25 minutes long. The practitioners — usually doctors, but sometimes nurse practitioners — were paid an average of $57 a visit.

The median payment — the point at which half the amounts are higher and half are lower — was $30,265.

Much of the spending was the result of an expensive and frequent treatment for a kind of age-related macular degeneration, the leading cause of severe vision loss in the elderly, and the cost of the drug is factored into the payments doctors receive. Ranibizumab, known by the brand name Lucentis, is injected into the eye as often as once a month. A cancer drug that is used as an alternative can cost much less.

Regulators and others are also likely to seize on some of this information to find those doctors who perform an unusually high volume of services, raising the question of whether every test or procedure, like the placement of a cardiac stent, was medically necessary.

“There’s a lot of potential for whistle-blowers and justified worry for fraudsters,” said Steven F. Grover, a lawyer who represents whistle-blowers who sue doctors and hospitals who they claim have committed fraud against the Medicare program.



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