April 2014 was not a great month for us ophthalmologists from a public relations standpoint. For several days, the dominant national health care story was the release of Medicare payment data for physicians. After years of legal fighting, Dow Jones, the publisher of The Wall Street Journal, obtained these data from the Centers for Medicare & Medicaid Services.1 The information was broken down by specialty, and the news for us was unflattering. Media coverage focused on how a very small percentage of physicians billed a very large percentage of the total dollars spent on the Medicare program. Ophthalmology was repeatedly singled out, with one-third of the top billers in Medicare belonging to our specialty. Buried deep in these articles, or ignored altogether, was that many of the top-billing ophthalmologists were simply passing through the cost of very high-priced pharmaceuticals for macular degeneration. Oncologists face a similar situation with their high-priced chemotherapy drugs. Some subsequent news coverage acknowledged the misleading nature of the data due to our use of expensive drugs,2 but at that point, the damage was done.
Also in April, The New York Times unhelpfully revealed that the highest biller in the entire Medicare universe was a Florida ophthalmologist who received $21 million in Medicare reimbursement in 2012.3 When the median household income in the United States is $52,100 per year,4 news of a doctor’s billing Medicare more than $80,000 per day is not going to win ophthalmology many fans. The article featured a photograph of an FBI agent carrying a box (presumably of files) in front of the Florida doctor’s practice. The article went on to state that the ophthalmologist in question had become a large donor to the Democratic Party’s causes and that Democratic New Jersey Senator Robert Menendez had intervened with federal officials on his behalf. The online version of the article also contains an interactive map titled, Medicare’s Most Reimbursed Ophthalmologists, reminiscent of the television program “America’s Most Wanted.” Visitors to the website can zoom in to street level to find the highest-billing ophthalmologists in their neighborhoods.
Fraudulent billing practices are unacceptable and criminal, but high billing volumes do not necessarily represent fraud. Although extreme outliers in billing volume will always attract scrutiny from regulators, the media is painting ophthalmology with a broad brush. This may be only the beginning.
Release of the database is the largest single public disclosure of physician practice pattern information in the history of the Medicare program. What will the consequences be? Now that physicians’ right to privacy has been ruled subordinate to the public’s right to access information, are more detailed data releases likely? Will insurers begin profiling physicians in an attempt to control costs? I believe so. What will that mean to doctors whose referral practices have higher-than-usual levels of pathology? As population demographics begin to overwhelm the Medicare system, will this database be used to sculpt public opinion against ophthalmology and other major billing specialties in a war over Medicare dollars? I believe it will.
Through our professional societies, we ophthalmologists must lobby Congress and the Centers for Medicare & Medicaid Services to clarify the misleading reporting of passthrough pharmaceutical fees as professional fees. We must defend the value proposition of cataract surgery, which I would argue is the single most transformative surgical procedure in all of medicine. Finally, if reimbursement drops to levels that are simply unsustainable, we must prepare to abandon a system that does not adequately support the work we perform.
- Weaver C, McGinty T, Radnofsky L. Small slice of doctors account for big chunk of Medicare costs. The Wall Street Journal. Updated April 9, 2014. http://online.wsj.com/news/articles/SB10001424052702303456104579490043350808268. Accessed May 23, 2014.
- Keating D, Rivero C, Downs K, Chow E. Database: how much Medicare pays doctors. The Washington Post. April 9, 2014. http://www.washingtonpost.com/wp-srv/special/national/medicare-doctors-database. Accessed May 23, 2014.
- Robles F, Lipton E. Political ties of top billers for Medicare. The New York Times. April 9, 2014. http://www.nytimes.com/2014/04/10/business/doctor-with-big-medicare-billings-is-no-stranger-to-scrutiny.html. Accessed May 23, 2014.
- Pear R. Median income rises, but is still 6% below level at start of recession in ’07. The New York Times. August 21, 2013. http://www.nytimes.com/2013/08/22/us/politics/us-median-income-rises-but-is-still-6-below-its-2007-peak.html. Accessed May 23, 2014.