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Medicare's open books [Editorial]

This week, America learned what the folks over on Security Boulevard already knew — there's a lot to be learned from Medicare accounting. Medicare paid out $77 billion to health care providers in 2012, according to the long-awaited data coming from the Baltimore-based Centers for Medicare and Medicaid Services, but some providers received a lot more than others.

Not surprisingly, this small exercise in transparency was blasted by some of the high earners who fret that the information can be misleading and unfair. They are correct — to a degree. That specialists like ophthalmologists and oncologists account for a much larger share than primary care doctors is not indicative of fraud (although it may be in some specific cases) but of the realities of 21st century care that are, nevertheless, just as concerning.

What is writ large by these numbers over and over again is the high cost of medication (a stunning $8.6 billion of the total). That immediately raises questions — familiar ones at that — of how short-sighted it is to ban the government from using its massive market share to negotiate better drug prices. But it is also a reminder that specialties like ophthalmology or vascular surgery that bill based on expensive procedures are inevitably better compensated in our fee-for-service health care system, regardless of their relative contribution to improving patients' health compared to less remunerative specialties like primary care.

Who are the biggest billers in Maryland? Nearly half of the top-10 lists are ambulance services, private and public. That Prince George's County and Baltimore City's fire departments are big ambulance billers likely has more to do with the lack of routine, preventive medical care in poor neighborhoods than it does about the service. When an elderly person in medical distress calls 911, we expect an ambulance to be dispatched to the scene, and there aren't a lot of costs to be cut from that equation. That Maryland is a slightly higher consumer of Medicare may point to nothing more notable than the availability of health care in the state.

Clearly, you can't look at the lists and say that this doctor is overbilling or that one is ripping off the system. There's just so far that you can take the numbers. But it is interesting to see where they point — like the two Florida doctors who received astronomical reimbursements from Medicare and also happen to be major Democratic Party donors. The doctor at the top, a North Palm Beach ophthalmologist, received a stunning $21 million, and according to a New York Times analysis, much of it came from prescribing Lucentis, an injectable antibody used to treat macular degeneration that is far more costly than Avastin (bevacizumab) but which has been shown in clinical trials to be no more effective than the cheaper drug in the treatment of vision loss.

Did the doctor in question do anything wrong? Not necessarily. But the public has the right to ask questions about such behavior and about Medicare's reimbursement policies. At least it makes for a much more thoughtful discussion than the vacuous anti-Obamacare rhetoric to which the nation has been subjected in recent months. If the U.S. is to pursue a more cost-effective health care system, exploring the ins and outs of Medicare billing is a great place to begin.

In releasing the data, U.S. Health and Human Services Secretary Kathleen Sebelius described it as a "new window into health care spending and physician practice patterns." If so, it's a window that needs to be made more clear. By itself, the data is merely suggestive — more like NSA metadata requiring extensive analysis that might or might not unlock secrets than a wire-tap producing evidence for prosecution. A lot is missing, from the medical history and health outcomes of the patients to the non-Medicare billing patterns of those same doctors.

Still, it's frustrating that it's taken this long for the public to get this limited view. U.S. taxpayers are, after all, the ones ultimately on the hook for Medicare costs. Privacy must be protected, but it shouldn't take decades to open the CMMS books. As physicians are so quick to point out, the best patient is an informed patient, and that requires asking questions. Do we really want a health care system where a tiny fraction of doctors and other providers get paid the largest share of our limited resources? This release of data may not answer the question, but it certainly does raise it.

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Copyright © 2015, The Baltimore Sun
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