On April 9, 2014, the annual payments individual physicians receive from Medicare were made public by the Centers for Medicare & Medicaid Services. This data had been confidential since 1979, after the American Medical Association successfully sued the government to keep the payment amounts secret. The Wall Street Journal filed suit in 2011, seeking public release of the data, and after additional Freedom of Information Act requests, CMS announced it would be made public.

The data, released on the CMS website, detail the amount individual providers were reimbursed for Medicare Part B services in 2012 and are broken down by CPT code, procedure type, number of units, and average charge. But interpretation of the data is not straightforward, particularly for emergency physicians who provide an assortment of services to a variety of patients.

“Although transparency is important, this data has so many confounders, it’s hard to reach clear conclusions,” said Michael Granovsky, MD, FACEP, president of LogixHealth, a national ED billing company.

Challenges to Analysis

While the data certainly highlight outliers who may be worthy of investigation—for example, a Florida-based ophthalmologist received $21 million from Medicare in 2012, according to the data, and he previously has been under investigation for Medicare fraud—additional details about the payments can provide important insights.

For instance, one of the highest-paid emergency physicians is credentialed in emergency medicine, yet most of his Medicare reimbursement was related to services performed at a vein clinic, the majority of which were endovenous laser procedures reimbursed at $1,133 each. Medicare paid him more than $1 million in 2012.

“The vein center services are not taking place in an ED and do not really have a direct relevance to ED care or costs,” said Dr. Granovsky. However, it’s there, embedded in the data along with everything else.

The CMS database includes more than 880,000 physicians with Medicare payments that rise as high as $20 million. Of these, 37,000 are emergency physicians with Medicare reimbursements of a few hundred dollars to nearly $2 million. Most range between a few tens of thousands to hundreds of thousands of dollars.

The wide discrepancy demonstrates that data alone do not tell the story.

“Typical ED groups receive annual Medicare reimbursement in the range of $50,000 to $80,000 per physician” said Dr. Granovsky, who analyzed a subset of representative data.

Part of what throws the CMS data off are outliers like the doctor in the vein clinic, or the vascular surgeon who ranks as the highest-paid “ED” physician in the CMS dataset. Medicare paid him more than $1.8 million in 2012. He is board certified in general surgery and vascular surgery, and the bulk of his payments came from the $733,641 of complex femoral-popliteal artery revascularizations he performed. Few ED services contributed to his Medicare payments.

Upon the release of the CMS database, The Wall Street Journal and The New York Times quickly developed online tools to help people access the data and to provide perspective. The 9 million records included in the dataset can also be downloaded in text-delimited format from the CMS website as a .zip file that is 1.7 GB when uncompressed. It must be imported into a database or into statistical software; otherwise, the data is unwieldy, said Dr. Granovsky.

A disclaimer on the CMS website highlights that the data may not represent the full scope of a physician’s practice nor is it indicative of the quality of care provided or the health of a physician’s patient population. The data also do not provide a barometer for the necessity of the tests and procedures performed or whether they were effective.

Still, it can be difficult to reconcile the fact that seven doctors received more than $10 million from Medicare in 2012 and 4,000 physicians were paid at least $1 million. In addition, a quarter of doctors in the dataset were responsible for capturing more than a third of the $77.4 billion in payments, and one in three of the top earners were ophthalmologists.

Radiation oncologists were also top earners on Medicare’s payroll. Fewer than 1,000 doctors within the specialty accounted for a total of $1.1 billion in payments.

A quarter of doctors captured more than a third of the $77.4 billion in payments, and one in three of the top earners were ophthalmologists.

Applications to Emergency Medicine

Dr. Granovsky recommends all emergency physicians compare the CMS data to their own billing records; those who find themselves to be significant outliers should take a deeper dive into the data. According to The Wall Street Journal, regulators are scrutinizing high-paying codes, especially in places like the ED. Hospitals and health systems are also using the information to better understand how to limit and control high costs.

Payments to emergency physicians are confounded by multiple factors. Those who own urgent care centers might receive Medicare payments for hundreds of thousands of dollars, but most of it relates to medication costs and ancillary services in the urgent care center, not the traditional ED evaluation and management services most emergency physicians report.

Additionally, the CMS data do not capture some of the critical clinical factors that determine how much aggregate Medicare reimbursement emergency physicians will receive, like the volume of Medicare patients in the ED, the types of shifts the physicians work, and whether they are scheduled in the main department or fast track. It also doesn’t identify certain hospital charges that may impact billing.

“ED physicians provide services to the patients that their hospital treats based on that hospital’s individual profile and resources, such as being a trauma center and having interventional cardiology services,” said Dr. Granovsky. “If your hospital has a lot of specialty services, a large volume of Medicare patients will be seen, and they will be more complex.”

Even factors such as proximity of urgent care centers will filter out lower-acuity patients and result in a higher ratio of more complex patients treated in the ED. Nearby nursing homes, too, can bring up the cost of providing care by simply contributing large volumes of patients.

The data release comes amid ongoing debate over how to better control costs in the Medicare program and how to rein in unnecessary care while improving patient outcomes. Medicare spending is near $600 billion annually, including payments to hospitals and physicians and costs for drugs. Cutting wasteful and fraudulent payments is one way to slow cost growth.

While the transparency intended by releasing the data might help some consumers choose which doctors they would like to see, when it comes to care in the ED, Dr. Granovsky is skeptical the information is useful for patients.

“I am not sure it is a valuable reference tool to help select an emergency department for care,” he said.

Kelly April Tyrrell is a freelance journalist based in Wilmington, Delaware.