On reading CMS Data

The New York Times has a great little tool that accesses the massive CMS data dump on provider reimbursement for Medicare Part B.  You can look up any Medicare Part B doc that has treated more than 11 patients in 2012 and see that they charged and what they got reimbursed.  There are a few caveats to this data set.

  • Primary address location is fairly arbitary.  I looked up my PCP.  He spends 60% of his time at an office a few blocks from my house.  He was not there.  His “primary” location according to the CMS data set is a location he spends one day a week at.  When he first came to the area, he worked at this location 100% of the time, but moved to my neighborhood five or six years ago.  His Medicare data profile has not been updated.  Unfortunately provider data that is not 100% neccessary for claims payment is splotchy.
  • Claims rolling up to a provider’s NPI or Medicare ID.  Non-MD/non-D.O. clinicians such as Certified Nurse Practicioners, Physician Assistants, Master and Doctorate level Physical Therapists etc. often will roll their billing up to a doctor’s Medicare billing number.  This means we can’t do a simple time management bullshit detection study based solely on “This provider is claiming he is doing 17 Medicare Part B procedures a day.  Each of these procedures takes 30 minutes… IMPOSSIBLE”.  That type of first level analysis might identify odd situations, but most will be explained by seeing three or four CRNPs/PAs doing most of the work that the doctor than bills for.
  • Medicare Advantage is not in this data set.  Some regions have lots of Medicare Advantage enrollment. Others don’t Some docs have a lot of Medicare Advantage patients.  Others don’t.  We can’t generalize too well to the entire Medicare population from the CMS data set.
  • No way to determine medical neccessity/particular skill.  This is pure counting data, it is not quality data.  Counting data is valuable as it can be used to look at odd counts, but there are plenty of good reasons for outliers.  For instance, a provider might be particulary good/renowned for putting shoulders back together, so that could be why his shoulder surgery count is so high compared to less aggressive treatment reimbursement codes as he was getting patients referred to him that needed surgery.  We can’t tell from this data if the patients were different or the doctor was different in treatment preferences.

This is very valuable data for geeks, but it is caveated and limited.  Nicholas Bagley at the Incidental Economist notes that information disclosure is not a particulary effective policy tool in and of itself.

Information disclosure is a common regulatory tool. It’s been studied a lot. And in most settings, it just doesn’t work…. Nor is it clear that employers and insurers will leverage the data in shaping their provider networks or honing their cost-control strategies. An extensive 2000 review of the evidence about publicly available information on provider quality concluded that “[n]either individual consumers nor group purchasers appear to search out, understand, or use the currently available information to any significant extent.”

…. Sure, the data will reveal some outlier physicians with outrageous billing habits. Patients should avoid those doctors. But what about a cardiologist who bills Medicare for stenting an unusually large number of patients? Is that a “bad” doctor with a penchant for inserting medically unnecessary stents? Or a “good” doctor with a thriving practice and a steady hand who inserts stents only where clinically indicated? How would you know?


22 replies
  1. 1
    GHayduke (formerly lojasmo) says:

    Holy. Shit. My bill for the inpatient addiction program (just for the month of February…I was released in March) was north of $41K

    I guess I’ll hit my OOP limit for 2014.

    ETA: My wife’s employer provided insurance has our primary care provider (really the only game in town) as out of network. As they are her primary insurer, every one of her bills goes through them, and is denied, before it goes to my insurer. I asked her to cancel her insurance, as it is such a headache.

  2. 2
    Richard Mayhew says:

    @GHayduke (formerly lojasmo): sounds like it

  3. 3
    maximiliano furtive, formerly known as dr. bloor says:

    @GHayduke (formerly lojasmo):

    But the meals, I’ll bet they were great, amirite?

    I guess I’m with Bagley on this one. I didn’t really get the OH NOEZ, PRIVACY thing pushed by the AMA, although just releasing into the wild a butt-ton of numbers as “caveated” as they are falls into the “a little knowledge is a dangerous thing” category.

  4. 4
    Ejoiner says:

    Slightly OT – but I’m getting hammered on FB with reposts from my conservative friends concerning the Ebony writer who now can’t find a doctor to take her with the ACA coverage (she claims she’s been turned down 96 times so far). Any chance you could address this and other similar situations in the near future. My understanding is that with greater insurance coverage comes greater demand and until the market corrects with more doctors there is going to be a shortage.

  5. 5
    Richard Mayhew says:

    @Ejoiner: I have not seen the article, but my bet is that she is in a super narrow network and did not realize it when she bought the policy, and now is stuck.

  6. 6
    jayackroyd says:

    What I take away from this is the focus of CMS/the medical technocrats is still on reducing utilization rather than cutting costs. But it’s not a bad thing that the headline item was on patent vs off patent drug treatment of macular degeneration.

    But the problem is still that US citizens pay something like twice as much for procedures than the rest of the OECD.

  7. 7
    jayackroyd says:


    The guy who treated my broken wrist is a hand surgeon. He had 20 odd instances of what looks like surgery to repair a pinched nerve in the ulnar region. According to the data dump he billed 5000 per encounter, but was paid 368 by Medicare. Is that possible?

  8. 8
  9. 9
    jayackroyd says:

    Begley closes with:

    When physicians choose to participate in Medicare, however, they assume obligations to the public that finances those expenditures. The public should have a chance to ask hard and sometimes uncomfortable questions about how physicians exercise that authority. Maybe, just maybe, the billing data will help build political support for the reforms that a 21st-century Medicare program so urgently needs.

  10. 10
    Richard Mayhew says:


    Yeah, a 93% difference between paid and asked is a bit high, but not unusual. When I got snipped, my commercial insurance was getting billed 97 dollars for a dose of local anethesia and the contract rate for pay-out was 58 cents I think.

    Most if not all insurers have logic in their claims systems to pay the lesser of the billed amount or the contracted amount. From a provider point of view, it never hurts to bill way above the contract rate. Worse comes to worse, the payer (insurer/Medicare/Medicaid) trims the payment to the contract rate. Better case scenario from the provider point of view is that there was a recent increase in the fee schedule that is now picked up. A high baseline rate allows the doc to get a better deduction for charitable care and uncollected debts.

  11. 11
    Mnemosyne says:


    I see the issue now — the writer is newly eligible for Medicaid and can’t find a Medicaid doctor. This is, sadly, not really a new problem, but it’s one that otherwise middle-class people haven’t run into before. It’s always been a problem of the poor and desperate, so no one was paying attention.

    Also, I’m surprised to hear that your mother is on Medicaid, not Medicare, at her age. That seems a little odd.

  12. 12
    Elizabelle says:


    RE the Ebony article: the young lady just got Medicaid coverage through Horizon in New Jersey, and she cannot find local doctors who will accept Medicaid patients.

    The Ebony comments section is a trollfest of slobbering conservatives with “what did you expect? — you should have listened to the Tea Party” jibes. And they’re high fiving each others’ comments.

    It is not filled with people who generally read Ebony, I would guess.

  13. 13
    Ejoiner says:

    Damn, you’re right – she’s on medicare. Shouldn’t try posting while at work, right before spring break with dozens of students running through the door trying to turn in late work right before the end of the grading period, huh? Thanks for the feedback :)

  14. 14
    Ejoiner says:

    Exactly – in fact I expect none of my FB friends who are reposting and gloating over this article have EVER touched an Ebony mag in their lives. Must be a great surge in their (digital?) subscriptions!

  15. 15
    Mnemosyne says:


    There actually are some people over 65 who have both Medicare and Medicaid coverage (especially if they’re in nursing homes), so it wasn’t totally implausible that your mother has Medicaid coverage. I was just confused. :-)

    And, unfortunately, it’s not that unusual for doctors to stop taking Medicare, especially if the local population of elderly people tend to be higher-income and are willing to pay out of pocket instead. I think they call it “concierge medicine.” Small towns are even worse (though I’m not sure if that’s where your mother lives).

  16. 16
    Elizabelle says:

    We have a mismatch of primary care doctors who will take Medicaid/Medicare reimbursement, whose rates should be revisited to make it more acceptable.

    We gots plenty of high-priced medical specialists, though. With their own highly expensive diagnostic equipment. Just like the doctor down the street’s. The medical equipment arms race.

    Best healthcare system in the world, hmmm?

  17. 17
    jayackroyd says:

    @Mnemosyne: Do you have any data on that? I’ve heard it anecdotally repeatedly, but have always had my doubts. I’ve heard second hand reports of doctors telling patients they’ll be forced to drop them, but they never seem to actually do so.

  18. 18
    Mnemosyne says:


    It’s tough to get exact statistics since they depend on each individual state’s medical associations (which have, shall we say, a vested interest in scaring people about Medicare) but it does look like the number of doctors who will accept new Medicare patients is going down. Part of the problem is the overall shortage of primary care physicians, though there are other issues as well. The Texas Medical Association in particular has been claiming that less than half of Texas doctors will take new patients.

  19. 19
    JaneE says:

    Analysis of this data will give you a list of people who may need to be looked at in greater detail. That’s about it. You can eliminate all the docs who don’t get over $X amount, and really scrutinize carefully the ones over $Y amount, but most of the ones in between will probably be justified in one way or another.

  20. 20
    Tom Ames says:

    That’s odd. According to the NYT tool, there are only 2 psychologists in San Francisco who got Medicare Part B payments.

    I’m thinking this is not quite a comprehensive database.

  21. 21
    Tom Ames says:

    @Tom Ames: Never mind: I see that “Clinical Psychologist” is also listed.

  22. 22
    bvernia says:

    This is a good article addressing some of the problems of interpreting CMS’s data. As someone who represents both whistleblowers and providers in fraud cases, I think the best thing that has come out of CMS’s data dump is the set of questions that people raise, which shed light on some of Medicare and Medicaid’s bizarre compensation practices. Case in point: the ophthalmologists singled out as big recipients, because of their use of expensive (and possibly unnecessarily so) drugs. The doctors have explained that they pass through most costs to the pharma companies (i.e., Genentech), but this just raises the question why the docs are being compensated on a percentage of the drug cost instead of some flat fee for administering it. This, and not the specifics of a given doctor’s practice, is the kind of helpful sunshine CMS’s data shines on the system.

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