Well, the cat is out of the bag now. All this time we’ve been told that Internal Medicine is a dying art, you can’t make a living at it, payments to physicians are too low, etc. Now the New York Times is telling me that Internal Medicine is fifth on the list of best-paid doctors! How can this be?
Here’s what has happened: Medicare has released the names and specialties of all the doctors it has paid in 2012. That’s a lot of data. It’s, well, Big Data. It’s data on two things: 1) doctors; 2) money. The healthcare reform debate in a nutshell. So this will likely get a lot of press. I haven’t seen the actual numbers yet, and I’m told it will take many weeks to go through all of it. Since nobody pays me to write, I’ll have to keep my day job, and thus will have to leave the number crunching to others.
Thankfully, the New York Times has come to my rescue. (http://www.nytimes.com/2014/04/09/business/sliver-of-medicare-doctors-get-big-share-of-payouts.html?hp&_r=0). According to the NYT, 880,000 practitioners and 77 billion dollars are covered in the report. Twenty-five percent of that 77 billion seems to have gone to two percent of doctors: those in opthalmology, oncology, and cardiology. Internal medicine is right behind, wouldn’t you know. The article actually has a chart that they named “The best-paid 2 percent of doctors”. Yep. Those family doctors are really raking it in.
The paper singles out a specific opthalmology procedure as a prominent, and, it implies, therefore suspect, reason for big payouts. In fact, the paper had to be asked (nicely) not to release the names of the actual doctors with the highest billing records, or to contact them, until all the data is released to the public. I suspect a couple of eye-doctors are going to have a really bad day today. The opthalmology data is a good illustration of how Big Data can be Limited Data. And how it can be interpreted a number of ways. The NYT is implying that because eye doctors’ billing is so high, and so much higher than other specialties, there must be some something criminal going on. Either eye doctors are committing fraud, or they are doing unnecessary procedures, or they are using drugs that are too expensive. The doctors must be wrong.
But the data doesn’t say that at all. All it says it that Medicare, which sets it’s reimbursement rates at levels mandated by Congress, not doctors, pays more money to treat people with eye diseases than it does other diseases. That’s it. It says nothing about a doctor’s practice at all. Nothing.
Let’s take a couple of examples. Opthalmology is a sub-specialized field. A doctor who does cataracts doesn’t do Lasik, or he does Lasik but he doesn’t handle macular degeneration, etc. A lot of specialties are getting like this. Now, say a few doctors have specialized in this one procedure the NYT is all upset about. Other doctors send their patients to these guys. All of their practices becomes doing this procedure. Because it’s their specialty. So they bill Medicare for the procedure. Medicare pays out what it decided to pay for this procedure. How is this the doctor’s fault? (By the way, funny story. There’s a Lasik advertisement on the internet page with this article.)
Another example. Say you are an oncologist. You treat a lot of blood cancers, leukemia and such. Other doctors send you their patients if they have leukemia. There are a lot of types of leukemia, many of which are very expensive to treat and some which actually become chronic. You bill Medicare for your treatments. Medicare pays back what it decided to pay for these treatments. It costs a lot to treat leukemia. That’s what the data says. That’s all it says. It says nothing about quality of care, patient population, number of patients, or disease complexity. It says nothing about variability in office visit time or the level of co-existing disease in a specific doctor’s patient population.
I am all for transparency. I think having this data out there is fine, as long as we understand what we are getting. And I’m not sure we do. Specific doctors are going to be targeted for a lot of scrutiny because of this report. Maybe they deserve to, maybe they don’t. Fraud and over-treatment do exist. But this data is far from telling the whole story.